Severe atopic dermatitis associated with symptoms of depression and internalizing behaviors in children

1. The findings of this longitudinal cohort study suggest an association between atopic dermatitis and symptoms of depression and internalizing behaviors starting in early childhood and persisting through adolescence.

2. With the global prevalence of atopic diseases increasing in children, health care providers must be cognizant of the psychosocial needs of children and adolescents with atopic dermatitis.

Evidence Rating Level: 2 (Good)

Study Rundown: Atopic dermatitis (AD), the most common inflammatory skin disease present in 20% of pediatric and 10% of adult populations worldwide, is known to be associated with a host of systemic comorbidities including asthma and allergic rhinitis. However, there is a growing body of evidence that supports an association between AD and mental health conditions including anxiety, depression, and suicidality, albeit with limited longitudinal data in the pediatric population.  This longitudinal cohort study sought to examine the association between AD and symptoms of depression and internalizing behaviors at multiple points across childhood and adolescence. Furthermore, the effects of potential mediating factors, including asthma and rhinitis, sleep, and inflammation were assessed. The main endpoints of the analysis were symptoms of depression, assessed through child-reported responses to the Short Moods and Feelings Questionnaire at 5 points from 10 to 18 years, as well as internalizing behaviors, assessed via maternal report to the Strength and Difficulties Questionnaire at 7 points from 4 to 16 years. Among 11,181 children enrolled in the study, severe AD was associated with approximately double the likelihood of developing symptoms of depression and internalizing behaviors throughout childhood and adolescence. Although mild to moderate AD was not associated with any symptoms of depression, it was associated with internalizing behaviors in children as young as 4 years old. These findings suggested an association between AD and symptoms of depression and internalizing behaviors starting in early childhood and persisting through adolescence. With the global prevalence of atopic diseases increasing in children, health care providers must be cognizant of the psychosocial needs of children and adolescents with AD. Lastly, the effects of current and new AD therapies on mental health outcomes and synergistic factors such as sleep, growth, and development in children must also be examined in future studies. A limitation of this study was that all outcomes data, including severity of AD, symptoms of depression, and internalizing behaviors, were based on child or maternal report; previous studies have observed an underestimation of the prevalence of internalizing behaviors reported by parents compared to self-report from children and adolescents.

Click to read the study in JAMA Dermatology

Relevant Reading: Association of atopic dermatitis with depression, anxiety, and suicidal ideation in children and adults: A systematic review and meta-analysis

In-Depth [prospective cohort]: This population-based birth cohort study included 11,181 children (5,721 male [51.2%]) from the UK Avon Longitudinal Study of Parents and Children, where the mean (SD) duration of follow-up from birth was 10.0 (2.9) years. Data was collected between September 1990 and December 2009 at 11 time points from 6 months to 18 years of age via standardized questions about flexural dermatitis, with analysis completed in July 2020. Overall, the period prevalence of depression symptoms and internalizing behaviors ranged from 6.0-21.6% and 10.4-16.0%, respectively. Specifically, mild to moderate AD was not associated with depression symptoms, however, it was associated with internalizing behaviors in children as early as 4 years (mean increased odds of 29-84% across childhood in adjusted models). Severe AD was associated with both depression symptoms (adjusted odds ratio, 2.38; 95%CI, 1.21-4.72) and internalizing behaviors (adjusted odds ratio, 1.90; 95%CI, 1.14-3.16). Although sleep quality was able to mediate some of the association between AD and mental health outcomes, it was not able to explain differences in sleep duration, history of atopy, or levels of inflammatory biomarkers.

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