Association between Atopic Dermatitis and Depression in US Adults
2015; Elsevier BV; Volume: 135; Issue: 12 Linguagem: Inglês
10.1038/jid.2015.337
ISSN1523-1747
AutoresSherry H. Yu, Jonathan I. Silverberg,
Tópico(s)Allergic Rhinitis and Sensitization
ResumoTO THE EDITOR Atopic dermatitis (AD) is associated with intense pruritus, high rates of sleep disturbance (Silverberg et al., 2015Silverberg J.I. Garg N.K. Paller A.S. et al.Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study.J Invest Dermatol. 2015; 135: 56-66Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar), stigma, increased healthcare costs (Silverberg, 2015Silverberg J.I. Health care utilization, patient costs, and access to care in US adults With eczema: a population-based study.JAMA Dermatol. 2015; 151: 743-752Crossref PubMed Scopus (80) Google Scholar) and poor quality of life (Silverberg et al., 2015Silverberg J.I. Garg N.K. Paller A.S. et al.Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study.J Invest Dermatol. 2015; 135: 56-66Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar). All of these might contribute toward higher rates of depression. Previous studies found that Taiwanese adolescents/adults with AD have a higher incidence of major depressive disorder than those without AD (1.42 vs. 0.20 per 1,000 person-years) (Cheng et al., 2015Cheng C.M. Hsu J.W. Huang K.L. et al.Risk of developing major depressive disorder and anxiety disorders among adolescents and adults with atopic dermatitis: a nationwide longitudinal study.J Affect Disord. 2015; 178: 60-65Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar), as well as a higher prevalence of depression in Korean males (10.4 vs. 5.3%) (Kim et al., 2015Kim S.H. Hur J. Jang J.Y. et al.Psychological Distress in Young Adult Males with Atopic Dermatitis: A Cross-Sectional Study.Medicine. 2015; 94: e949Crossref PubMed Scopus (43) Google Scholar). A recent study found that US children with AD had significantly higher prevalences of ever having depression (6.5%) and current depression (3.9%) compared with those without AD (3.4% and 1.8%, respectively) (Yaghmaie et al., 2013Yaghmaie P. Koudelka C.W. Simpson E.L. Mental health comorbidity in patients with atopic dermatitis.J Allergy Clin Immunol. 2013; 131: 428-433Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar). However, the prevalence of depression in US adults with AD is not known. We studied participants from the 2005–2006 NHANES and 2012 National Health Interview Survey. Both surveys were sponsored and conducted by National Center for Health Statistics (NCHS) of Centers for Disease Control and Prevention. Households were selected through a stratified, randomized, multistage, and probability-cluster design. Health interviews were conducted in the home in either English or Spanish. The survey results were weighted to represent the population of non-institutionalized adults nationally and in each state using data from the U.S. Bureau of the Census, and to account for the complex survey design, survey non-response and post-stratification. This study was approved by the institutional review board at the Northwestern University. The questions used to assess for history of eczema and depression are shown in Supplementary Table 1 online. In NHANES, respondents were asked questions from the Patient Health Questionnaire (PHQ), a validated self-reported assessment based on the nine DSM-IV symptoms for depression (Spitzer et al., 1999Spitzer R.L. Kroenke K. Williams J.B. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.JAMA. 1999; 282: 1737-1744Crossref PubMed Scopus (6831) Google Scholar; Arroll et al., 2010Arroll B. Goodyear-Smith F. Crengle S. et al.Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population.Ann Fam Med. 2010; 8: 348-353Crossref PubMed Scopus (707) Google Scholar). A binary variable was also created based on the SIGECAPS criteria (acronym for depression symptoms), which are predictive of major depressive disorder when ≥4/8 positive responses are combined with depressed mood for at least two week (Carlat, 1998Carlat D.J. The psychiatric review of symptoms: a screening tool for family physicians.Am Fam Physician. 1998; 58: 1617-1624PubMed Google Scholar). PHQ scores were classified as none (score 0–4), mild (score 5–9), moderate (score 10–14), and severe (score 15–27) depression. Download .pdf (.03 MB) Help with pdf files Supplementary Tables All data processing and statistical analyzes were performed with SURVEY procedures in SAS version 9.4 (SAS Institute, Cary, NC). Complete data analysis was performed. Associations between AD and depression were tested via logistic regression models. In NHANES, the dependent variables included the nine PHQ9 questions, SIGECAPS, and total PHQ9 depression score. In NHIS, the dependents variables were self-reported history of depression ever or in the past year. The independent variable was history of AD. Multivariate models included age, gender, race/ethnicity, level of education, family poverty income ratio, history of asthma and hay fever. Crude and adjusted prevalence odds ratios (OR) and 95% confidence intervals (CIs) were estimated. A total of 5,555 adults (≥18 years) were included in NHANES 2005–2006. The prevalence of AD was 6.2% (95% CI: 5.6–6.8%). AD was associated with female gender, poverty income ratio ≥4, greater than high school or GED equivalent education, history of asthma and hay fever (Supplementary Table 2 online). One hundred and nine adults (31.0%) with AD reported one or more symptoms of depression. In multivariate survey logistic regression models of NHANES data that controlled for socio-demographics, history of asthma and hay fever, AD was associated with higher odds of having little interest in doing things, feeling down, depressed or hopeless, feeling tired or having little energy, having a poor appetite, feeling bad themselves, having trouble concentrating and moving or speaking slowly or too fast and having thoughts of being better off dead (Table 1).Table 1Association between depression and eczema in US adults from NHANES 2005–2006 (n=5,555)VariableOutcomesEczemaNoYesFreq.Percent (95% CI)Freq.Percent (95% CI)Crude OR (95% CI)P-valueAdjusted OR (95% CI)P-valueLittle interest in doing thingsNone3,61681.34 (79.93, 82.75)23274.59 (68.78, 80.41)1.00—1.00—Several days62013.61 (12.35, 14.87)5116.51 (11.45, 21.57)1.32 (0.90, 1.94)0.151.26 (0.85, 1.88)0.26More than half the days1603.03 (2.44, 3.62)205.98 (2.92, 9.04)2.17 (1.21, 3.89)0.0092.45 (1.35, 4.47)0.003Nearly every day1142.02 (1.57, 2.48)102.92 (0.77, 5.07)1.57 (0.71, 3.47)0.271.94 (0.85, 4.42)0.12Feeling down depressed, or hopelessNone3,54280.22 (78.79, 81.66)22572.86 (66.99, 78.72)1.00—1.00—Several days71515.09 (13.79, 16.40)5216.10 (11.25, 20.95)1.19 (0.82, 1.73)0.371.25 (0.84, 1.85)0.27More than half the days1572.89 (2.32, 3.45)226.25 (3.09, 9.41)2.39 (1.34, 4.26)0.0032.57 (1.40, 4.71)0.002Nearly every day991.80 (1.35, 2.24)154.79 (1.93, 7.65)2.91 (1.48, 5.73)0.0023.32 (1.63, 6.78)0.001Trouble sleeping or sleeping too muchNone2,95765.20 (63.43, 66.97)19261.99 (55.61, 68.36)1.00—1.00—Several days99723.23 (21.64, 24.82)7323.82 (18.22, 29.43)1.09 (0.79, 1.52)0.591.00 (0.70, 1.42)0.98More than half the days2655.91 (5.04, 6.78)215.62 (2.62, 8.62)1.01 (0.56, 1.83)0.980.97 (0.53, 1.78)0.93Nearly every day2935.66 (4.85, 6.48)278.57 (4.96, 12.17)1.58 (0.97, 2.59)0.071.68 (0.99, 2.86)0.06Feeling tired or little energyNone2,29851.43 (49.58, 53.29)12939.31 (32.92, 45.70)1.00—1.00—Several days1,58535.47 (33.69, 37.25)11940.59 (34.08, 47.10)1.50 (1.11, 2.04)0.0091.38 (1.00, 1.89)0.048More than half the days3317.07 (6.13, 8.00)3911.57 (7.39, 15.74)2.13 (1.35, 3.37)0.0011.93 (1.18, 3.14)0.009Nearly every day2996.03 (5.20, 6.87)278.53 (4.82, 12.25)1.86 (1.10, 3.13)0.021.89 (1.09, 3.27)0.02Poor appetite or overeatingNone3,58280.53 (79.08, 91.98)22775.55 (66.67, 78.43)1.00—1.00—Several days64013.65 (12.38, 14.92)5114.24 (9.85, 18.63)1.16 (0.79, 1.69)0.461.16 (0.78, 1.72)0.46More than half the days1433.24 (2.58, 3.90)175.56 (2.31, 8.80)1.89 (0.98, 3.63)0.061.72 (0.90, 3.31)0.10Nearly every day1492.58 (2.06, 3.11)197.65 (4.01, 11.29)3.28 (1.88, 5.73)<0.00013.61 (1.96, 6.65)<0.0001Feeling bad about yourselfNone3,88786.60 (85.35, 87.84)24477.84 (72.45, 83.27)1.00—1.00—Several days46710.41 (9.29, 11.54)4515.03 (10.31, 19.76)1.63 (1.10, 2.40)0.021.49 (0.98, 2.27)0.06More than half the days811.57 (1.12, 2.02)144.30 (1.69, 6.92)3.08 (1.53, 6.18)0.0023.07 (1.48, 6.38)0.003Nearly every day791.42 (1.00, 1.83)102.83 (0.82, 4.83)2.22 (1.01, 4.88)0.0482.73 (1.20, 6.22)0.02Trouble concentratingNone3,83185.58 (84.30, 86.86)23777.11 (71.58, 82.64)1.00—1.00—Several days49710.58 (9.45, 11.70)4615.16 (10.29, 20.03)1.60 (1.08, 2.39)0.021.51 (0.99, 2.30)0.05More than half the days982.14 (1.60, 2.68)205.13 (2.39, 7.86)2.69 (1.44, 5.03)0.0022.84 (1.42, 5.67)0.003Nearly every day881.70 (1.26, 2.14)112.60 (0.75, 4.45)1.69 (0.78, 3.65)0.191.88 (0.85, 4.18)0.12Moving or speaking slowly or too fastNone4,09291.93 (90.96, 92.90)26785.57 (81.00, 90.15)1.00—1.00—Several days3025.83 (4.99, 6.66)3911.87 (7.67, 16.07)2.19 (1.42, 3.36)0.00042.21 (1.43, 3.43)0.0004More than half the days741.59 (1.15, 2.04)51.64 (0.00, 3.42)1.16 (0.36, 3.69)0.811.30 (0.39, 4.40)0.67Nearly every day420.65 (0.39, 0.91)30.92 (0.00, 2.00)1.52 (0.43, 5.42)0.522.06 (0.55, 7.71)0.28Thought better off deadNone4,36597.16 (96.58, 97.74)29996.23 (93.91, 98.55)1.00—1.00—Several days1132.19 (1.69, 2.71)81.85 (0.21, 3.48)0.86 (0.34, 2.18)0.761.16 (0.46, 2.95)0.76More than half the days260.45 (0.21, 0.69)61.70 (0.09, 3.32)3.79 (1.27, 11.37)0.024.90 (1.53, 15.70)0.008Nearly every day120.20 (0.05, 0.34)10.22 (0.00, 0.64)1.13 (0.14, 9.24)0.911.41 (0.15, 13.15)0.76Difficulty these problems have causedNone at all2,17773.97 (71.+9, 75.96)15371.16 (64.21, 78.12)1.00—1.00—Somewhat difficult67822.41 (20.53, 24.29)5824.25 (17.69, 30.81)1.12 (0.77, 1.63)0.561.18 (0.80, 1.74)0.39Very difficult712.73 (1.97, 3.49)83.67 (0.64, 6.70)1.36 (0.55, 3.37)0.511.41 (0.53, 3.74)0.49Extremely difficult260.89 (0.48, 1.29)40.92 (0.00, 1.84)1.09 (0.36, 3.31)0.881.20 (0.37, 3.95)0.76SIGECAPS criteriaNo3,97789.5 (88.4, 90.6)50882.5 (77.6–87.4)1.00—1.00—Yes25010.5 (9.4–11.6)6117.5 (12.6–22.4)1.81 (1.26–2.59)0.0011.89 (1.28–2.77)0.001PHQ9 scoreNone (0–4)3,86087.0 (85.0–88.2)24277.9 (72.4–83.4)1.00—1.00—Mild (5–9)4048.6 (7.6–9.6)3310.9 (6.6–15.2)1.41 (0.89–2.25)0.141.46 (0.91–2.36)0.12Moderate (10–14)1613.1 (2.5–3.7)225.4 (2.7–8.2)1.97 (1.10–3.51)0.022.24 (1.20–4.17)0.01Severe (15–27)771.4 (1.0–1.8)165.8 (2.7–8.8)4.64 (2.46–8.75)<0.00015.64 (2.88–11.07)<0.0001Abbreviations: CI, confidence interval; Freq, frequency; OR, odds ratio; PHQ9, patient health questionnaire; SIGECAPS, depression acronym for disturbances in at least 4/8 symptoms with depressed mood: sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal.Binary survey logistic regression models were constructed for individual PHQ9 questions, PHQ9 depression score (none (score 0–4), mild (score 5–9), moderate (score 10–14), severe (15–27)) and SIGECAPS depression criteria (no, yes (at least 4/8 criteria with depressed mood)) as the independent variables and history of eczema as the dependent variable. Multivariate models included age, gender, race/ethnicity, education, poverty income ratio, history of hay fever and asthma as the dependent variables. Crude and adjusted prevalence ORs and 95% CIs were estimated. Open table in a new tab Abbreviations: CI, confidence interval; Freq, frequency; OR, odds ratio; PHQ9, patient health questionnaire; SIGECAPS, depression acronym for disturbances in at least 4/8 symptoms with depressed mood: sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal. Binary survey logistic regression models were constructed for individual PHQ9 questions, PHQ9 depression score (none (score 0–4), mild (score 5–9), moderate (score 10–14), severe (15–27)) and SIGECAPS depression criteria (no, yes (at least 4/8 criteria with depressed mood)) as the independent variables and history of eczema as the dependent variable. Multivariate models included age, gender, race/ethnicity, education, poverty income ratio, history of hay fever and asthma as the dependent variables. Crude and adjusted prevalence ORs and 95% CIs were estimated. The prevalence of depression as judged by the SIGECAPS criteria was higher in adults with AD compared with adults who did not have eczema (17.5 vs. 10.5%; adjusted OR (95% CI): 1.89 (1.28–2.77)). Moreover, AD was associated with higher odds of moderate (2.24 (1.20–4.17)) and severe (5.64 (2.88–11.07)) depression as judged by the PHQ9 score. A total of 34,613 adults were included in NHIS 2012. The US prevalence (95% CI) of eczema in adults was 7.2% (6.9–7.6%). The associations of adult eczema in NHIS 2012 were previously described (Silverberg et al., 2015Silverberg J.I. Garg N.K. Paller A.S. et al.Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study.J Invest Dermatol. 2015; 135: 56-66Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar). The lifetime prevalence of healthcare diagnosed depression was higher in adults with AD compared with adults who did not have AD (26.9 vs. 13.1%; adjusted OR (95% CI): 2.29 (2.02–2.61) (Table 2). In addition, AD was associated with higher odds of depression in the past year (2.31 (2.00–2.66)). There were no significant statistical interactions between history of AD and other covariates as predictors of depression.Table 2Association between depression and eczema in US adults from NHIS 2012 (n=34,613)VariableEczemaNoYesFreqPercent (95% CI)FreqPercent (95% CI)Crude OR (95% CI)P-valueAdjusted OR (95% CI)P-valueEver history of depression No27,41286.9 (86.4–87.3)1,74573.1 (70.8–75.4)1.00—1.00— Yes4,67113.1 (12.7–13.6)74126.9 (24.6–29.2)2.44 (2.15–2.76)<0.00012.29 (2.02–2.61)<0.00011-year history of depression No28,75090.7 (90.3–91.1)1,92380.1 (78.0–82.1)1.00—1.00— Yes3,3299.3 (8.9–9.7)56319.9 (17.9–22.0)2.44 (2.12–2.80)<0.00012.31 (2.00–2.66)<0.0001Abbreviations: CI, confidence interval; OR, odd ratio.Binary survey logistic regression models were constructed with ever and 1-year history of depression as the binary dependent variables and history of eczema as the independent variable. Multivariate models included age, gender, race/ethnicity, education, poverty income ratio, history of hay fever and asthma as the dependent variables. Crude and adjusted prevalence ORs and 95% CIs were estimated. Open table in a new tab Abbreviations: CI, confidence interval; OR, odd ratio. Binary survey logistic regression models were constructed with ever and 1-year history of depression as the binary dependent variables and history of eczema as the independent variable. Multivariate models included age, gender, race/ethnicity, education, poverty income ratio, history of hay fever and asthma as the dependent variables. Crude and adjusted prevalence ORs and 95% CIs were estimated. These results confirm and expand on previous international studies that have found a higher rates of depression among adults with AD (Gupta and Gupta, 1998Gupta M.A. Gupta A.K. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.Br J Dermatology. 1998; 139: 846-850Crossref PubMed Scopus (714) Google Scholar; Cheng et al., 2015Cheng C.M. Hsu J.W. Huang K.L. et al.Risk of developing major depressive disorder and anxiety disorders among adolescents and adults with atopic dermatitis: a nationwide longitudinal study.J Affect Disord. 2015; 178: 60-65Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar; Kim et al., 2015Kim S.H. Hur J. Jang J.Y. et al.Psychological Distress in Young Adult Males with Atopic Dermatitis: A Cross-Sectional Study.Medicine. 2015; 94: e949Crossref PubMed Scopus (43) Google Scholar). We were unable to assess the direction of association between AD and depression; however, it is likely bidirectional. That is, AD increases the risk for depression (Gupta and Gupta, 1998Gupta M.A. Gupta A.K. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis.Br J Dermatology. 1998; 139: 846-850Crossref PubMed Scopus (714) Google Scholar; Cheng et al., 2015Cheng C.M. Hsu J.W. Huang K.L. et al.Risk of developing major depressive disorder and anxiety disorders among adolescents and adults with atopic dermatitis: a nationwide longitudinal study.J Affect Disord. 2015; 178: 60-65Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar; Kim et al., 2015Kim S.H. Hur J. Jang J.Y. et al.Psychological Distress in Young Adult Males with Atopic Dermatitis: A Cross-Sectional Study.Medicine. 2015; 94: e949Crossref PubMed Scopus (43) Google Scholar), whereas stress may trigger AD (Oh et al., 2010Oh S.H. Bae B.G. Park C.O. et al.Association of stress with symptoms of atopic dermatitis.Acta Derm Venereol. 2010; 90: 582-588Crossref PubMed Scopus (91) Google Scholar). Either way, the results of the present study and prior studies suggest that adults with AD are at higher risk for depression and would benefit from increased screening for depression. This study has several strengths, including similar results using two large-scale, randomly sampled, diverse databases using sampling weights that allow for generalizability to the entire adult US population. PHQ9 and SIGECAPS are extensively validated screening questionnaires for depression. We previously performed a multicenter validation study and found that the question used in NHANES for eczema has excellent sensitivity, specificity, positive and negative predictive values (Silverberg et al., 2015Silverberg J. Patel N. Immaneni S. et al.Assessment of atopic dermatitis using self- and caregiver- report: a multicenter validation study.Br J Dermatology. 2015; (e-pub ahead of print 17 July 2015)https://doi.org/10.1111/bjd.1403Crossref Google Scholar). Previous studies also found good concordance between self-reported eczema and AD diagnosed by medical examination (Susitaival et al., 1995Susitaival P. Husman L. Hollmen A. et al.Dermatoses determined in a population of farmers in a questionnaire-based clinical study including methodology validation.Scand J Work Environ Health. 1995; 21: 30-35Crossref PubMed Scopus (54) Google Scholar; Flohr et al., 2009Flohr C. Weinmayr G. Weiland S.K. et al.How well do questionnaires perform compared with physical examination in detecting flexural eczema? Findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two.Br J Dermatology. 2009; 161: 846-853Crossref PubMed Scopus (88) Google Scholar). However, the question used in NHIS did not specify healthcare-diagnosed AD, which may decrease its specificity. It is possible that some of the higher rates of depression observed in NHIS may be attributable to other inflammatory skin disorders. However, the similar prevalences of depression in the past year in NHIS and SIGECAPS in NHANES suggest that the higher prevalence observed are in fact from depression. We were able to control for many potentially confounding factors in multivariate regression models. This study also has several limitations. Questions pertaining to history of depression in NHIS were based on self-report and not confirmed clinically through physician report or billing. However, the similarity between prevalence estimates from self-report of healthcare diagnosis in NHIS and SIGECAPS in NHANES suggests the results of both studies are valid. In conclusion, approximately one in three US adults with AD reported any symptoms of depression and one in three adults with AD met diagnostic criteria for major depressive disorder. Future research is needed to determine whether improved treatment of AD might prevent or mitigate depressive symptoms in adults. JIS had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. JIS contributed to study concept and design; SHY and JIS helped in acquisition of data; SHY and JIS analyzed and interpreted data, and drafted the manuscript; and SHY and JIS provided critical revision of the manuscript for important intellectual content and helped in statistical analysis. This publication was made possible with support from the Agency for Healthcare Research and Quality (AHRQ), grant number K12HS023011, and the Dermatology Foundation. Supplementary material is linked to the online version of the paper at http://www.nature.com/jid
Referência(s)