Suicidal ideation in patients with atopic dermatitis: A case‐control study on 23,191 adults

Abstract

Due to its substantial psychosocial burden, atopic dermatitis (AD) is linked to an increased risk of suicidal ideation (SI).1-3 As part of the ‘Scars of Life’ study,4 we conducted a case–control analysis to assess the prevalence and risk factors of SI in a sample of adults representative of the general population with physician-confirmed AD, compared to adults without AD from the same population, across 27 countries. The survey collected sociodemographic variables, a subjective evaluation of SI (‘have you had suicidal ideation: in the last 24 months? before the age of 18’), itch and skin pain intensity (Visual Analog Scale, VAS), clinical severity [CSv] (POEM5) and skin-related stigmatization (PUSH-D6). Participants were contacted by email to complete a structured digital questionnaire. Among 15,223 individuals with current AD (8726 women, 6497 men), mean age was 41.1 years (SD 14.1). Of these, 7383 (48.5%) had adult-onset AD, 4965 (32.6%) adolescent-onset (10–18 years) and 2875 (18.9%) childhood-onset (<10 years). A control group [CG] composed of 4063 women and 3905 men, with a mean [SD] age of 43.7 [15.6] years, did not report AD. In the past 24 months, 2009 (13.2%) AD patients reported SI, compared to 678 (8.5%) in the CG (p < 0.01). The relative risk of SI in AD patients was thus 1.55 [95%CI: 1.42–1.69]-p < 0.001. In the adult-onset group, 12.7% reported SI during adolescence; however, in the group with childhood-onset and adolescence-onset, suicidal ideation was reported by respectively 29.1% (838/2875) and 16.8% (832/4965) (p < 0.001). Regardless of the age of onset, AD was significantly associated with a higher risk of SI compared with the CG, with slightly higher odds in early-onset forms: adult-onset: OR = 1.56 [1.41–1.73]-p < 0.0001; adolescence-onset: OR = 1.71 [1.53–1.91]-p < 0.0001; childhood-onset: OR = 1.72 [1.50–1.96]-p < 0.0001. Among AD patients reporting SI (Table 1), there were higher stigmatization feelings (PUSH-D score), more women, younger people (<30 years) and more people suffering from obesity compared to those not reporting SI, as well as higher AD severity, pruritus and skin pain. The frequency of pruritus, skin pain, and insomnia was also significantly higher in individuals reporting SI. The multivariable analysis (Figure 1) confirmed these results. The high prevalence of SI in patients with AD was reported in other studies, such as in a meta-analysis,2 where mean rates of SI were 1.8 times (16.8%/9.1%) higher than controls. Also, previous studies observed an association of SI in AD with severity,5 obesity,6 pruritus,1 and sleep disorders.5 All these aspects are interconnected.7, 8 For example, severe pruritus, the main sleep disruptor in AD, contributes to the development of depression and anxiety, both risk factors for SI.9 Moreover, stigma related to AD6 is a key psychosocial factor in the increased risk of SI, interacting with different aspects, such as severity, pain, sleep disturbances and depression. Beyond the current high prevalence of SI, we found that many adult patients with early AD onset recalled experiencing SI during adolescence. Suicide is a major cause of mortality among adolescents worldwide. Large-scale studies showed up to a 44% increased risk of suicidal thoughts and a 36% higher risk of attempts3 compared to adolescents without AD, highlighting AD as a serious public health concern requiring integrated care. Key strengths of our study include the large, population-based sample10, 11 and the stratification by age of onset. Limitations include the assessment of SI without a validated psychiatric tool, a possible recall bias in reporting adolescent SI, the cross-sectional design, which does not allow causal inference and the lack of psychiatric comorbidity data, which could confound the associations. Our findings highlight that SI is not only common in adults with AD but often begins in adolescence, underscoring the need for suicide risk screening and mental health support in dermatological care, especially for early-onset cases. The study was designed by La Roche-Posay Laboratoire Dermatologique, France. Ann'Laure Demessant-Flavigny, Caroline Le Floc'h, Nabil Kerrouche and Delphine Kerob are employees of La Roche-Posay Laboratoire Dermatologique, France. Charles Taieb received fees from La Roche-Posay Laboratoire Dermatologique, France, for setting up and overseeing this project. Julien Seneschal, Bruno Halioua, Jerry Tan, Chaoying Gu, Thomas Luger, Roni Dodiuk-Gad, Roberto Takaoka, Flavia Pretti Aslanian, Cita Rosita Sigit Prakoeswa, Delphine Kerob, Abraham Getachew Kelbore, Laurent Misery, Therdpong Tempark, Alexander Stratigos, Martin Steinhoff and Jonathan I. Silverberg received fees for participating in the project's scientific committee [methodology validation, questionnaire development and manuscript writing]. Charbel Skayem, Stéphanie Merhand, Wendy Smith Begolka, África Luca de Tena Smith and Shulamit Burstein did not receive any fees. The project was reviewed by a French ethics committee and was found to be in accordance with the ethical standards set forth by that committee. IDRCB 2023-A02722-43 [Committee for the Protection of Individuals South-East I dated 11 March 2024]. This pragmatic study was designed and conducted in accordance with the Declaration of Helinski (2013) and CIOMS guidelines (2016). All participants confirmed their consent after being informed of the objectives and benefits of the study. Data were collected and processed in accordance with data protection regulations, including the GDPR. The data that support the findings of this study are available from the corresponding author upon reasonable request.