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Brief Report
January 16, 2019

Assessment of a Bidirectional Association Between Major Depressive Disorder and Alopecia Areata

Author Affiliations
  • 1Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 2Section of Dermatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 3Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 4Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 5Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
JAMA Dermatol. 2019;155(4):475-479. doi:10.1001/jamadermatol.2018.4398
Key Points

Question  Is there a bidirectional association between major depressive disorder and alopecia areata?

Findings  This cohort study of over 6 million patients found that patients with major depressive disorder were at a 90% increased risk of developing alopecia areata and that antidepressants have a protective effect on this risk. Patients with alopecia areata had a 34% increased risk of developing major depressive disorder.

Meaning  Alopecia areata can affect mental health, and in turn mental illness can affect the development of alopecia areata; this bidirectional association suggests common underlying inflammatory and genetic susceptibilities between the brain and skin that require further study.

Abstract

Importance  Alopecia areata (AA) is an autoimmune disease characterized by hair loss that can impose a substantial psychological burden on patients, including major depressive disorder (MDD), yet many patients report mental health symptoms prior to the onset of AA. As such, there may be an association between MDD and AA that acts in both directions.

Objective  To assess the bidirectional association between MDD and AA.

Design, Setting, and Participants  This population-based retrospective cohort study included patients 10 to 90 years of age registered with The Health Improvement Network in general practices in the United Kingdom between January 1, 1986, and May 16, 2012. Statistical analysis was conducted from August 17, 2017, to April 23, 2018. To assess the risk of AA, the following 2 cohorts were defined: patients with an incident diagnosis of MDD (exposure) and a reference general population cohort. To assess the risk of MDD, the following 2 cohorts were defined: patients with an incident diagnosis of AA (exposure) and a reference general population cohort. Person-time was partitioned into unexposed and exposed time in the exposure cohorts.

Main Outcomes and Measures  In the analysis of the risk of AA, development of incident AA during follow-up was considered the main outcome measure. In the analysis of the risk of MDD, development of incident MDD during follow-up was considered the primary outcome measure.

Results  In the analysis of the risk of AA, 405 339 patients who developed MDD (263 916 women and 141 423 men; median age, 36.7 years [interquartile range, 26.6-50.5 years]) and 5 738 596 patients who did not develop MDD (2 912 201 women and 2 826 395 men; median age, 35.8 years [interquartile range, 25.3-52.6 years]) were followed up for 26 years. After adjustment for covariates, MDD was found to increase the risk of subsequently developing AA by 90% (hazard ratio, 1.90; 95% CI, 1.67-2.15; P < .001). Antidepressants demonstrated a protective effect on the risk of AA (hazard ratio, 0.57; 95% CI, 0.53-0.62; P < .001). In the analysis of the risk of MDD, 6861 patients who developed AA (3846 women and 3015 men; median age, 31.5 years [interquartile range, 18.2 years]) and 6 137 342 patients who did not develop AA (3 172 371 women and 2 964 971 men; median age, 35.9 years [interquartile range, 27.0 years]) were followed up for 26 years. After adjustment for covariates, AA was found to increase the risk of subsequently developing MDD by 34% (hazard ratio, 1.34; 95% CI, 1.23-1.46; P < .001).

Conclusions and Relevance  These temporal analyses suggest that, while patients with AA are at risk for subsequently developing MDD, having MDD also appears to be a significant risk factor for development of AA, with antidepressant use confounding this risk.

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