Atopic Eczema in Adulthood and Risk of Depression and Anxiety: A Population-Based Cohort Study

1What is already known about this topic? Atopic eczema is a common debilitating skin condition. An association between atopic eczema and common mental disorders is well documented, but its nature and temporal direction remain unclear.What does this article add to our knowledge? Individuals affected with atopic eczema are more likely to develop new depression (14% increased incidence) and anxiety (17% increased incidence). The observed dose-response relationship between atopic eczema severity and depression supports a causal mechanism for the association.How does this study impact current management guidelines? Recent atopic eczema guidelines comment briefly on the influence of psychological and emotional factors on the clinical course of atopic eczema. Our findings suggest that depression and anxiety should be addressed explicitly in updated guidelines.

2What is already known about this topic? Atopic eczema is a common debilitating skin condition. An association between atopic eczema and common mental disorders is well documented, but its nature and temporal direction remain unclear.

3What does this article add to our knowledge? Individuals affected with atopic eczema are more likely to develop new depression (14% increased incidence) and anxiety (17% increased incidence). The observed dose-response relationship between atopic eczema severity and depression supports a causal mechanism for the association.

4How does this study impact current management guidelines? Recent atopic eczema guidelines comment briefly on the influence of psychological and emotional factors on the clinical course of atopic eczema. Our findings suggest that depression and anxiety should be addressed explicitly in updated guidelines.

5Atopic eczema (eczema, atopic dermatitis) is a chronic relapsing inflammatory skin disease. It can cause intense itching and discomfort. Itch and disfiguring lesions result in sleeplessness and social embarrassment, impairing the quality of life of both sufferers and their families., Atopic eczema is common (20% of children and up to 10% of adults in developed countries) and is a major cause of years lost because of disability.,, Emerging evidence suggests that biologic agents, an effective treatment modality for severe atopic eczema,,, may also reduce symptoms of depression and anxiety among people with atopic eczema.

6Mental health disorders are one of the leading causes of disability worldwide, with depression and anxiety together accounting for more than half of that burden. Depression, manifesting as loss of interest and enjoyment in ordinary things and experiences, affects approximately 4.4% of the global population; anxiety disorders, characterized by excessive fear, anxiousness, or avoidance of perceived threats, affect approximately 3.6%. Both depression and anxiety are associated with increased morbidity and mortality.,,,, Atopic eczema has been shown to be associated with common mental disorders (depression and anxiety) and suicidality in cross-sectional studies that have frequently relied on self-reported exposures and outcomes.,,,,,,,,, Individuals with atopic eczema may be more likely to experience depression and anxiety through the effects of itch and discomfort, disfigurement, and perceived social-stigmatization,,; in addition, poor sleep related to atopic eczema may increase the risk of mental illness., Inflammatory mediators in atopic eczema could also contribute to the development of depression., However, those with depression and anxiety could also be more likely to consult for a physical condition such as atopic eczema. Because longitudinal evidence is scarce and conflicting, the temporality of any association between atopic eczema and depression and anxiety, and whether the relationship changes with increasing atopic eczema severity, remains unclear.,,

7Insight into the temporal relationship between atopic eczema and depression/anxiety could guide the clinical approach to this vulnerable group with visible and potentially stigmatizing skin disease. Atopic eczema is common, so if people with atopic eczema are indeed at increased risk of new-onset depression or anxiety, then this would suggest: (1) a major population impact; (2) a potential role for targeted mental health screening for individuals with atopic eczema; and (3) the possibility of mental health modification through improved atopic eczema control (eg, using new biologic agents). Therefore, we aimed to investigate the association between atopic eczema and newly diagnosed depression and anxiety, and whether any association increased with increasing atopic eczema severity, through a longitudinal analysis of UK primary care electronic health record data.

8We conducted a cohort study, using routinely collected primary care electronic health record data from practices contributing to the UK Clinical Practice Research Datalink (CPRD) and linked hospital admissions data from the Hospital Episode Statistics (HES) database. The CPRD covers approximately 7% of the UK population, is broadly representative of the general population, and includes demographic information, diagnoses, prescriptions, and secondary care referrals. Diagnoses are recorded in the CPRD using Read codes, and have been demonstrated to be valid., The CPRD ensures high-quality data through algorithmic analysis of gaps in data entry and deaths recorded by each practice. HES includes data on all the National Health Service–funded inpatient hospital stays in England since 1997, including diagnoses recorded using the International Classification of Diseases, Tenth Revision coding system. Linkage to HES data is available in approximately 80% of English CPRD practices. The study period was from January 2,1998, to March 31, 2016.

9The study protocol was approved by the Independent Scientific Advisory Committee (ISAC) for the CPRD (ISAC protocol no. 16_100RA) and the London School of Hygiene and Tropical Medicine (Reference: 15460). Informed consent was not required, because the study used anonymized data.

10Atopic eczema diagnosis was based on a validated algorithm (positive predictive value of 82%) requiring a record of at least 1 diagnostic code for atopic eczema and at least 2 records for atopic eczema therapy. Systemic glucocorticoids were not included in the validated algorithm to identify atopic eczema, and their use is generally discouraged (see this article's “Codes and treatments used in algorithm definition of atopic eczema” section in the Online Repository at www.jaci-inpractice.org). Other inclusion criteria were: adults 18 years and older; eligible for HES linkage; registered with a CPRD practice meeting CPRD patient- and practice-level quality control standards; and contribution of valid follow-up time during the study period (January 2, 1998, to March 31, 2016).

11To capture the progressive nature of atopic eczema and to avoid immortal-time bias, atopic eczema severity was modeled as a time-updated variable. We categorized severity into 3, mutually exclusive, progressive categories (mild, moderate, and severe) according to recorded atopic eczema therapy.,, By default, all individuals with atopic eczema were classified as having mild disease. They could be recategorized as having (1) moderate atopic eczema if potent topical steroids or calcineurin inhibitors were prescribed or (2) severe atopic eczema, if there was a record for a referral to a dermatologist, or a record for systemic treatment. Individuals with moderate/severe disease kept their severity category until the end of follow-up and could not be recategorized as having milder disease (see this article's “Codes and treatments used in algorithm definition of atopic eczema” section).

12Each atopic eczema–exposed individual was matched (without replacement) with up to 5 individuals without atopic eczema on sex, age, general practice, and calendar time. Unexposed individuals had no record of a diagnostic code for atopic eczema (in CPRD or HES) but were required to have at least 1 year of follow-up in CPRD as well as meet all other inclusion criteria. To minimize selection bias due to the exclusion of unmatched individuals and closely adjust for its effects, age was matched in 15-year strata and used as the underlying time scale for all analysis. To avoid misclassifying unexposed person-time, individuals could contribute unexposed person-time until the date of their first record of a diagnostic code for atopic eczema, regardless of later therapies prescribed (see Figure E1 in this article's Online Repository at www.jaci-inpractice.org).

13We considered depression and anxiety as separate outcomes, with onset defined as the date of the first recorded diagnosis in either CPRD or HES (any inpatient hospital diagnosis). Codes for the depression outcome were those compatible with unipolar depression, and for the anxiety outcome, included those consistent with generalized anxiety and panic disorders. We considered broader definitions of depression and anxiety in prespecified sensitivity analyses (see this article's “Code lists for the outcomes (depression and anxiety)” section in the Online Repository at www.jaci-inpractice.org).

14Individuals entered the cohort at the latest of: practice registration date plus 12 months; the date their practice met CPRD quality control standards; the date an individual met our atopic eczema diagnosis definition; or the start of the study (January 2, 1998). Individuals without atopic eczema entered the cohort on the same day as their matched atopic eczema–exposed case. We included a mandatory “wash-in” period of 12 months before cohort entry to ensure adequate time to capture true incident outcome diagnoses, as well as other baseline variables (eg, body mass index [BMI] and smoking).

15Cohort members were followed until the first of the following events: anxiety or depression diagnosis (depending on analysis); a diagnosis suggesting an alternative cause for each outcome (ie, organic depression or dementia for depression analyses; obsessive-compulsive disorder or post-traumatic stress disorder for anxiety analyses; and schizophrenia or bipolar disease for both depression and anxiety analyses); record of a morbidity code for an atopic eczema diagnosis (for the unexposed group); death date recorded in CPRD; end of registration with practice; last data collection from practice; or the end of the study (March 31, 2016).

16Covariate selection was guided by a literature review and construction of a directed acyclic graph to avoid collider bias, (see this article's “Directed acyclic graph” section, Figure E2, and Tables E1 and E2 in the Online Repository at www.jaci-inpractice.org). Age, calendar period, sex, and level of deprivation (as quintiles of the Index of Multiple Deprivation score) and ethnic group were deemed plausibly associated with both exposure and outcome, and not on the causal pathway (ie, potential confounders). We considered BMI, smoking status, harmful alcohol use, and high-dose oral glucocorticoid as possible mediators of the association between atopic eczema and depression/anxiety. The data sources and definitions used to identify all covariates are detailed in this article's “Algorithms to identify BMI and steroid use data” and “Algorithms to identify BMI and steroid use data” sections in the Online Repository at www.jaci-inpractice.org and morbidity code lists are available to download.

17We assessed the effect of the atopic eczema exposure on each outcome (depression or anxiety) using Cox regression stratified by matched set. We included the covariates used for matching in an initial crude model (implicitly adjusted for sex and general practice by stratification on matched set, and for age through the underlying timescale). We then adjusted for the remaining prespecified potential confounders (calendar period and Index of Multiple Deprivation) in an adjusted model. Finally, we also further adjusted for potential mediators of the relationship between atopic eczema and depression/anxiety (BMI; smoking; harmful alcohol and high-dose oral glucocorticoid use) in a third model. To preserve matching, analyses only included valid matched sets; that is, entire matched sets were excluded if the atopic eczema–exposed individual was excluded (because of preexisting outcome diagnosis at cohort entry, or because of missing BMI or smoking data in the models including possible mediators of the relationship between atopic eczema and depression/anxiety), or if no individuals without atopic eczema remained in the set.

18The absolute incidence rates of new depression and anxiety could be directly calculated among those with atopic eczema, but matching precluded a similar approach in those without atopic eczema (because this was not a representative sample of the general population). We, therefore, estimated incidence rates in those without atopic eczema by multiplying rates in those with atopic eczema by the corresponding estimated hazard ratio (HR) (after inverting it to compare unexposed with exposed). We calculated attributable risks as the difference between the incidence rates in those with and without atopic eczema, and the population-attributable risks by using the estimated HR and assuming the prevalence of atopic eczema to be 10%.

19We conducted a series of sensitivity analyses to explore possible sources of bias introduced by: strict definitions of the psychiatric diagnoses; use of a “mixed” incident and prevalent cohort; differential practice attendance; or restrictive algorithm-based definitions of atopic eczema (see Table E3 in this article's Online Repository at www.jaci-inpractice.org).

20In prespecified secondary analyses, we (1) redefined atopic eczema exposure using atopic eczema severity as a time-updated variable and compared incidence rates of depression and anxiety in those with mild, moderate, or severe atopic eczema to those with no atopic eczema and (2) explored possible effect modification of the relationship between atopic eczema and depression/anxiety by age, sex, and calendar period.

21We checked the proportional hazards assumption for the main analysis models through visual inspection of Schöenfeld residual plots. All P values reported are based on likelihood-ratio tests, with 99% CI. Statistical analysis was performed using Stata, version 15.1 (StataCorp LP, College Station, Texas).

22We identified 3,095,838 adults aged 18 years or older, including 526,808 with atopic eczema, and matched them to 2,569,030 without eczema (Figure 1). Further exclusions of individuals with relevant preexisting psychiatric diagnoses on or before the start of follow-up yielded 2,467,791 participants in the cohort for analyses with depression as the outcome, and 2,650,629 with anxiety as the outcome (all belonging to “valid sets,” that is, matched sets with at least 1 exposed and 1 unexposed individual). Median follow-up was similar in both cohorts: 4.7 (interquartile range, 1.6-8.6) years for individuals with atopic eczema and 4.2 (interquartile range, 1.9-9.1) years for those without atopic eczema (Table I). The mean age of the atopic eczema–exposed individuals was 43.9 ± 21.7 years in the depression cohort and 44.1 ± 21.43 years in the anxiety cohort.

23Participants with atopic eczema were less likely to have missing BMI values or smoking status, compared with those without atopic eczema, and those with missing information were more likely to be young and male (see Tables E4 and E5 in this article's Online Repository at www.jaci-inpractice.org).

24We explored diagnoses compatible with unipolar depression, generalized anxiety disorder, and panic disorders as the primary outcomes. There was a 1.14-fold (99% CI, 1.12-1.16) increase in the HR for depression in those with atopic eczema compared with those without, after adjusting for age, sex, general practice, current calendar period, and Index of Multiple Deprivation at cohort entry (Table II. For full model, see Table E6 in this article's Online Repository at www.jaci-inpractice.org). Atopic eczema was also associated with a 1.17-fold (99% CI, 1.14-1.19) increase in the risk of anxiety. Both estimates were attenuated after additionally adjusting for BMI, smoking status, harmful alcohol use, and high-dose glucocorticoid use (variables that may mediate the relationship between atopic eczema and depression/anxiety) (depression: HR, 1.10; 99% CI, 1.10-1.12; anxiety: HR, 1.12; 99% CI, 1.10-1.15). The absolute excess risk of depression/anxiety among those with atopic eczema that could be considered due to atopic eczema (attributable risk) was 160 per 100,000 person-years with atopic eczema (99% CI, 146-186) for depression and 144 per 100,000 for anxiety (99% CI, 115-153) although the excess risk of depression/anxiety in the population that could be considered due to atopic eczema (population-attributable risk) was 1.4% (95% CI, 1.2-1.6) for depression and 1.7% (1.4-1.9) for anxiety (see Table E7 in this article's Online Repository at www.jaci-inpractice.org) (these estimates were calculated assuming a 10% prevalence of atopic eczema and would increase if atopic eczema were more common).

25Our sensitivity analyses showed broadly similar effect estimates—those from the main analysis (Table E3).

26Regardless of atopic eczema severity level, we saw evidence for an association between atopic eczema and both depression and anxiety (Figure 2). Compared with those without atopic eczema, the risk of depression increased with increasing atopic eczema severity (P <.0001 for linearity; P =.3832 for departure from linearity in the adjusted model; and P =.6983 for departure from linearity in the model additionally adjusted for potential mediators). However, the results of analyses exploring the relationship between atopic eczema severity and anxiety did not demonstrate a similarly clear dose-response relationship; for mild and moderate atopic eczema, there was some evidence of a similar dose-response increase, but there was strong statistical evidence for departure from linearity (P <.0001) (see Table E8 in this article's Online Repository at www.jaci-inpractice.org).

27We saw some evidence (P <.0001) for sex modifying the effect of atopic eczema on depression, with a slightly higher risk of depression in those with atopic eczema compared with those without in men (1.19; 99% CI, 1.16-1.23) than in women (1.11; 99% CI, 1.08-1.13). We saw a similar pattern for risk of anxiety in those with and without atopic eczema after stratifying on sex (HR [99% CI]: men, 1.22 [99% CI, 1.17-1.27]; women, 1.14 [99% CI, 1.11-1.17]; P =.0003 for interaction). We also saw evidence for effect modification by current age, with the HR comparing those with atopic eczema to those without for both depression (P <.0001) and anxiety (P =.0052) being higher in those aged 40 to 59 years, compared with younger and older age groups. There was no evidence of a change in the effect of atopic eczema on both depression (P =.3229) and anxiety (P =.287) in different calendar periods (see Table E9 in this article's Online Repository at www.jaci-inpractice.org).

28We found that (treated) atopic eczema was associated with a 14% increase in the risk of newly diagnosed depression (adjusted HR; 99% CI, 1.12-1.16) and a 17% increase in the risk of a subsequent anxiety diagnosis (adjusted HR; 99% CI, 1.14-1.19). These associations were only slightly attenuated after further adjusting for potential mediators of the association between atopic eczema and anxiety/depression (BMI, smoking status, and alcohol and high-dose glucocorticoid use) and were present at all levels of atopic eczema disease severity. Risk of a new depression diagnosis increased linearly with increasing atopic eczema severity, providing strong evidence for a dose-response association. The outcomes were diagnoses compatible with unipolar depression, generalized anxiety disorder, and panic disorders, but we considered broader definitions of depression/anxiety in subsequent sensitivity analyses.

29We identified a large, nationally representative sample of people, the largest reported to date,, ensuring precise effect estimations and increased generalizability. We used a validated diagnostic algorithm to identify atopic eczema in primary care, and relied on highly specific physician diagnoses rather than self-reported outcomes.,, We chose the covariates included in the analysis on the basis of a priori reasoning (see this article's “Directed acyclic graph” section; Figure E2). Although some chronic conditions may be associated with atopic eczema, as well as with depression/anxiety, in the context of this study, we did not consider these conditions fit the definition for confounding because the potential confounder (chronic comorbidity) could be considered to be either a consequence of the outcome (anxiety/depression), or to mediate the relationship between exposure and outcome (see this article's “Directed acyclic graph” section).

30We deemed other factors (ie, BMI, smoking, systemic glucocorticoids, harmful alcohol use) as likely mediators of the effect of atopic eczema on depression and anxiety, rather than confounders; we consequently adjusted for these variables separately. Atopic eczema may be associated with the later development of conditions such as cardiovascular disease and various malignancies,, but exploring the potential mediating role of chronic comorbidity was beyond the scope of our analysis.

31The study also has several limitations. The algorithm we used to define atopic eczema excluded untreated individuals, reducing its sensitivity to detect milder cases. This limitation was mitigated by the availability of primary care data, because 97% of those with atopic eczema in the United Kingdom are managed in primary care,, and by including emollients, which are routinely prescribed for atopic eczema in the United Kingdom. The results also remained robust in sensitivity analyses using less-restrictive atopic eczema definitions. Analyses stratified by atopic eczema severity provided further reassuring evidence of an association between atopic eczema and anxiety/depression even among mild cases. However, our definition of atopic eczema severity might have misclassified individuals with severe atopic eczema as having less severe disease if they refused medical therapy. Misclassification of disease status or severity may have overestimated or underestimated the real association between severity of eczema and anxiety/depression because early symptoms of depression/anxiety could influence diagnostic and treatment preferences. However, general practitioners recorded their depression/anxiety diagnoses independently and prospectively, so reverse causality likely affected all study participants equally regardless of atopic eczema status (ie, nondifferential misclassification, suggesting bias toward the null rather than a spurious association).

32A further limitation of our eczema severity definition was that we were unable to capture symptom reduction or resolution (absence of a record for eczema does not necessarily mean absence in symptoms). Consequently, we considered individuals as having moderate or severe disease from the date they met the respective definition, and may therefore have wrongly classified people as having moderate/severe eczema when their symptoms had reduced or resolved. The result of wrongly classifying individuals as having more severe disease when their symptoms had actually remitted would only be to dilute the effect of eczema severity on depression/anxiety and bias our effect estimate to null.

33Follow-up began in adulthood, resulting in a mixed cohort of prevalent and incident (newly diagnosed) atopic eczema cases, introducing possible bias due to left truncation (ie, the possibility of an outcome event occurring before cohort entry), with consequent underestimation or overestimation of the effect of atopic eczema on depression and anxiety. However, following only incident cases when exploring predominantly adult-onset outcomes would have shortened follow-up and limited the study's power. In addition, the exact onset date of a relapsing condition such as atopic eczema cannot be captured accurately in routinely collected data. In such circumstances, a dynamic cohort including prevalent cases is preferred. A sensitivity analysis offered evidence against bias introduced by including both “incident” and prevalent atopic eczema cases in our cohort because it showed broadly similar results in those with prevalent atopic eczema and those more likely to have new-onset atopic eczema.

34Smoking status and/or BMI were not recorded for some study participants, and it is likely that whether smoking status/BMI was recorded or not was dependent on having atopic eczema or anxiety/depression (ie, missing not-at-random). BMI and smoking status are often captured opportunistically and are therefore more likely to be recorded in those who consult their general practitioner more frequently (due to health-seeking behavior or chronic conditions). Although previous studies suggested no clear-cut association between physical illness and detection of psychiatric diagnoses in primary care,, the possibility of selection bias when applying complete case analysis (ie, including only those with complete data) remains. In our study, this did not affect the main analysis, because the variables containing missing data were not included in the main adjusted analysis (they were considered as potential mediators). Comparable results from the model including smoking and BMI also provide evidence against substantial bias introduced by missing data. Finally, general practitioners do not routinely record patients' quality of sleep, and we were not able to assess the extent to which itch-related sleep disturbances mediate the development of depression and anxiety among people with atopic eczema.

35An association between atopic eczema, depression, and anxiety has been described in cross-sectional and case-control studies, in which the temporal sequence (ie, whether atopic eczema precedes depression or anxiety, or vice versa) could not be determined.,,,,,, The few longitudinal studies that addressed this question had inconsistent results.,, These studies were limited by short follow-up windows; inclusion of selected, nonrepresentative populations (eg, male military conscripts or secondary care diagnoses, ); no account of atopic eczema disease severity,; low-quality or no individual-level information on lifestyle variables,; and reliance on disease-specific medication usage as a nonspecific proxy measure to ascertain depression and anxiety., Notably, a recent Danish cohort study demonstrated point estimates that were in line with the estimates reported in our study, but the association was not evident in the adjusted models that included health care consumption.

36Atopic eczema, like several other chronic conditions, is associated with depression/anxiety. The link to chronic mental illness further supports the view of atopic eczema as a systemic disorder. Our results suggest that the association between atopic eczema and depression/anxiety is not substantially mediated through glucocorticoid treatment, obesity, smoking, or harmful alcohol intake. Evidence against a dose-response association between atopic eczema severity and anxiety could not only imply different pathophysiological mechanisms but also reflect misclassification of outcome, because the anxiety outcome was more heterogeneously defined. Our findings suggest that atopic eczema was more strongly associated with depression and anxiety in those aged 40 to 59 years (compared with younger and older age groups). However, it is unclear why; further research could investigate possible explanations for differences in the association between atopic eczema and depression/anxiety risk in those at different ages (eg, different age-specific coping strategies, or increased health care contacts due to active cardiovascular screening in that age group). Future research could also support our findings of a dose-response association between atopic eczema and depression/anxiety by including people with more severe forms of these conditions (eg, identified using prescriptions for antidepressants and anxiolytic medications).

37Although our results apply directly to UK primary care, they are likely to be relevant in other settings, especially where there is primary care–oriented universal access to health care. Mental illness is underdiagnosed in people with skin or other chronic diseases,,, but their detection and treatment might improve atopic eczema control by facilitating better adherence to skin disease treatment, or through direct anti-inflammatory actions of antidepressants. Current UK guidelines address only the management of atopic eczema in children, emphasizing the importance of assessing the psychosocial well-being and quality of life. Recent guidelines from the European Academy of Dermatology and Venereology comment briefly on the influence of psychological and emotional factors on the clinical course of atopic eczema. Neither of these guidelines mentions the long-term mental health implications of atopic eczema. Our findings suggest that depression and anxiety should be addressed explicitly in future guideline updates. Further research is needed to explore and define possible mediators; to characterize subpopulations at increased risk (eg, those with adult-onset atopic eczema, or those with more active variants of the disease); and to elucidate the feasibility and effectiveness of screening, early detection, and prevention of depression and anxiety among those with atopic eczema.

38Individuals affected with atopic eczema were more likely to develop depression and anxiety, regardless of atopic eczema severity. Strong evidence for a dose-response relationship between atopic eczema severity and depression supports a causal association. These results highlight the importance of a comprehensive bio-psycho-social approach to limit common mental disorders in those with atopic eczema and could guide recommendations for the management of atopic eczema.