Severe AD Leads to 2-Fold Increase in Depression, Anxiety Across Childhood

By Mara Shapiro, Staff Writer

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According to a recent study published in JAMA, patients with severe atopic dermatitis (AD) had a 2-fold increase in their likelihood to present with depression and internalizing symptoms throughout childhood. In cases of mild to moderate AD, no association was found with depression, but internalizing behaviors began as early as age 4.

“Longitudinal data with repeated assessments of AD and mental health are needed to understand potential associations throughout childhood. The heterogeneous, waxing and waning nature of AD makes it important to examine disease course over time to account for variations in disease activity and severity. Similarly, childhood and adolescence are particularly critical times for the development of mental illness and are characterized by rapid fluctuations of severity across short intervals,” report Chloe Kern, BA, and colleagues. 

Researchers performed a longitudinal cohort study using data collected from the Avon Longitudinal Study of Parents and Children (ALSPAC). The ALSPAC is an intergenerational, longitudinal cohort that recruited pregnant women living in Avon, UK who were expecting their child between 1991 and 1992. For this study, the sample consisted of 11,181 individuals who completed at least one assessment of AD and one mood questionnaire.

Depression was measured using child-reported responses to the Short Moods and Feeling Questionnaire (SMFQ) given at 5 points between age 10 and age 18. A score of 11 or higher was used to identify individuals with symptoms of depression.

Internalizing behaviors were measured through a maternal report of the Emotional Symptoms subscale of the Strength and Difficulties Questionnaire (SDQ) given at 7 points between age 4 and age 16. Mothers were asked to rate their child’s behavior on a scale of 0 (not true), 1 (somewhat true), or 2 (certainly true) for statements like “I worry a lot” or “I have many fears”. A score greater than the 90th percentile of the sample was considered a binary indicator for internalizing behavior, which corresponds to an Emotional Symptoms score of at least 4.

Out of the 11,181 individuals studied, 51.2% were male and 48.8% were female. Children in this study were followed for a mean duration of 10 years. From age 3 to age 18, the annual period prevalence of active AD decreased from 19.1% to 14.5%.mong those reporting active AD, the proportion reporting moderate or severe symptoms during the prior 12 months ranged from 21.8% to 40.1%.

The period prevalence of symptoms of depression as measured by the SMFQ increased from 6.0% at age 10 to 21.6% at age 18. When looking at the association with AD severity, there was no association with mild or moderate disease, but there was an association with severe disease. In cases of severe AD, there were increasing odds of symptoms of depression. In a sensitivity analysis using numerical SMFQ scores, participants with AD had a 0.3 point higher SMFQ score with any AD (95% CI, 0.08-0.55) and a 1.71 point higher SMFQ score with severe AD (95% CI, 1.23-2.78).

Period prevalence of internalizing behavior, as measured by a score of 4 or greater on the Emotional Symptoms subscale of the SDQ, ranged from 10.4% to 16.0% from age 4 to age 16. Like with depression, AD severity played a role in determining risk for internalizing behavior. However, even in mild and moderate AD there was a 29% to 84% increased risk of internalizing behavior.

Limitations of this study that warrant consideration are that all of the data used in this study came from self reported or parental reported means so there may be some degree of bias present. However, researchers note that similar results have been seen based on clinician diagnosis. In addition, a lack of ethnic diversity was also present in the ALSPAC cohort, so further research is needed in more diverse populations.

“This longitudinal cohort analysis offers evidence of an association between AD and symptoms of depression and internalizing behavior beginning in early childhood. Because many new AD therapies are being brought to market, it is important to study the effect of new therapies on sleep and mental health outcomes among pediatric patients,” conclude Kern and colleagues. “The large and increasing burden of pediatric mental illness highlights the importance of clinician awareness of the psychosocial needs of children and adolescents with AD.”

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