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Original Investigation
September 1, 2021

Association of Atopic Dermatitis and Mental Health Outcomes Across Childhood: A Longitudinal Cohort Study

Author Affiliations
  • 1Department of Dermatology, University of California, San Francisco
  • 2Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 3Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
  • 4Department of Pediatrics, University of California, San Francisco
  • 5Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 6Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
  • 7Division of Epidemiology, School of Public Health, University of California, Berkeley
JAMA Dermatol. 2021;157(10):1200-1208. doi:10.1001/jamadermatol.2021.2657
Key Points

Question  Is atopic dermatitis (AD) associated with symptoms of depression and internalizing behaviors throughout childhood and adolescence?

Findings  In this cohort study of 11 181 participants, severe AD was associated with an approximately 2-fold increase in the likelihood of symptoms of depression and internalizing symptoms across childhood. Although mild to moderate AD was not associated with symptoms of depression, it was associated with internalizing behaviors as early as 4 years of age.

Meaning  The findings of this cohort study suggest that, because AD is common and associated with symptoms of depression and internalizing behaviors in early childhood, future work research should evaluate the role of early screening and interventions.

Abstract

Importance  Research has highlighted associations between atopic dermatitis (AD) and mental health conditions in adults. However, literature on the development of mental health comorbidities in children is limited despite the large burden of pediatric AD worldwide.

Objective  To examine the association between AD and internalizing behaviors and symptoms of depression at multiple points across childhood and adolescence and to explore potential mediating factors, including asthma/rhinitis, sleep, and inflammation.

Design, Setting, and Participants  This longitudinal, population-based birth cohort study included children followed up from birth for a mean (SD) duration of 10.0 (2.9) years from the UK Avon Longitudinal Study of Parents and Children. Data were collected from September 6, 1990, to December 31, 2009. Data were analyzed from August 30, 2019, to July 30, 2020.

Exposures  Annual period prevalence of AD assessed at 11 points from 6 months to 18 years of age, measured by standardized questions about flexural dermatitis.

Main Outcomes and Measures  Symptoms of depression, measured using child-reported responses to the Short Moods and Feelings Questionnaire at 5 points from 10 to 18 years of age and internalizing behaviors, measured by maternal report of the Emotional Symptoms subscale of the Strength and Difficulties Questionnaire at 7 points from 4 to 16 years of age.

Results  Among the 11 181 children included in the analysis (5721 male [51.2%]), the period prevalence of symptoms of depression ranged from 6.0% to 21.6%; for internalizing behaviors, from 10.4% to 16.0%. Although mild to moderate AD was not associated with symptoms of depression, it was associated with internalizing behaviors as early as 4 years of age (mean increased odds of 29%-84% across childhood in adjusted models). Severe AD was associated with symptoms of depression (adjusted odds ratio, 2.38; 95% CI, 1.21-4.72) and internalizing symptoms (adjusted odds ratio, 1.90; 95% CI, 1.14-3.16). Sleep quality mediated some of this association, but it was not explained by differences in sleep duration, asthma/rhinitis, or levels of inflammatory markers (interleukin 6 and C-reactive protein).

Conclusions and Relevance  Within this population-based birth cohort study in the UK, severe AD was associated with symptoms of depression and internalizing behaviors throughout childhood and adolescence. Risk of internalizing symptoms was increased even for children with mild AD beginning early in childhood, highlighting the importance of behavioral and mental health awareness in this population.

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    1 Comment for this article
    EXPAND ALL
    RE: Association of Atopic Dermatitis and Mental Health Outcomes Across Childhood
    Tomoyuki Kawada, MD | Nippon Medical School
    Kern et al. conducted a prospective study to evaluate the association between atopic dermatitis (AD) and mental health conditions in children from 6 months to 18 years of age (1). Although mild to moderate AD was not associated with symptoms of depression, severe AD was associated with symptoms of depression, presenting adjusted odds ratio (OR) (95% confidence interval [CI]) of 2.38 (1.21-4.72). In addition, mild to moderate AD was significantly associated with internalizing symptoms and adjusted OR (95% CI) of severe AD for internalizing symptoms was 1.90 (1.14-3.16). Furthermore, sleep quality mediated the association between AD and mental health conditions. I present prospective studies, which was not quoted by kern et al.

    Cheng et al. reported the association between AD and mental health in subjects aged 12 and older (2). The adjusted hazard ratios (HRs) (95% CIs) of AD in adolescents for major depression, any depressive disorder, and anxiety disorders were 4.26 (1.39-13.13), 4.38 (2.09-9.18) and 5.40 (2.02-14.39), respectively. Wei et al. also reported the association between AD and affective disorders, and the adjusted HRs (95% CIs) of adolescent AD for developing major depression and bipolar disorder were 2.45 (1.93-3.11) and 2.51 (1.71-3.67), respectively (3). In addition, the adjusted HRs (95% CIs) of adolescent AD with one, two and ≥3 atopic comorbidities for major depression were 1.80 (1.29-2.50), 2.42 (1.93-3.04) and 3.79 (3.05-4.72), respectively. Furthermore, the adjusted HRs (95% CIs) of adolescent AD with one, two and ≥3 atopic comorbidities for bipolar disorder were 1.40 (0.57-3.44), 2.81 (1.68-4.68) and 3.02 (1.69-5.38), respectively. This means that there was a significant dose-response relationship between AD and affective disorders, especially in major depression.

    Kern et al. explored mediators on the association between adolescent AD and mental health conditions, and sleep quality had an effect on the association. Although the mechanism of the association may be complicated, I also speculate the risk of poor sleep on subsequent mental health problems in adolescents by a case report of sleep monitoring in patients with AD (4).

    References
    1. Kern C, Wan J, LeWinn KZ, et al. Association of Atopic Dermatitis and Mental Health Outcomes Across Childhood: A Longitudinal Cohort Study. JAMA Dermatol 2021;157(10):1200-8.
    2. Cheng CM, Hsu JW, Huang KL, 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;178:60-5.
    3. Wei HT, Lan WH, Hsu JW, et al. Risk of developing major depression and bipolar disorder among adolescents with atopic diseases: A nationwide longitudinal study in Taiwan. J Affect Disord 2016;203:221-6.
    4. Kawada T. Monitoring of activity by wrist accelerometer in patients with atopic dermatitis. Clin Exp Dermatol 2010;35(2):193-4.
    CONFLICT OF INTEREST: None Reported
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