The relationship between suicidal behaviors and atopic dermatitis in Korean adolescents

Abstract

Atopic dermatitis is a common skin disease in adolescents, which may have a negative effect on the mental and emotional health. We investigated the relationship between atopic dermatitis and suicidal behaviors in Korean adolescents. Participants included 74,186 adolescents (38,221 boys and 35,965 girls) in middle and high school who completed the Eighth Korea Youth Risk Behavior Web-Based Survey. There were significant associations between atopic dermatitis and suicidal behaviors for girls. The overestimation of weight perception might have an additive impact on suicidal risk among girls. However, there were no significant associations between atopic dermatitis and suicidal behaviors in boys.

Keywords

atopic dermatitis distorted weight perception Korea Youth Risk Behavior Web-Based Survey suicidal ideation suicidal planning suicide attempt

Introduction

Atopic dermatitis has become a global public health concern due to increasing prevalence and mounting economic burdens (Carroll et al., 2005). It is a common inflammatory skin disease occurring most frequently in children, and it displays notable clinical findings, such as pruritus, erythema, and lichenification (Eichenfield et al., 2014). Patients with atopic dermatitis have chronically recurrent unrelenting symptoms and frequently experience the negative effects of various comorbidities associated with atopic dermatitis. Pruritus can affect sleep and mood of patients, and affected individuals are also at risk for psychosocial difficulties that may have long-lasting consequences, potentially affecting personal relationships (Carroll et al., 2005). In addition, children and adolescents with atopic dermatitis often have a lower quality of life and greater psychological distress, sleep disturbance, depressive mood, anxiety, and behavior disorders (Brown et al., 2013; Chamlin, 2006; Yaghmaie et al., 2013).

Suicide is one of the leading causes of death among adolescents in many countries (Patton et al., 2009). In the latest annual report of vital statistics, suicide was the leading cause of death among Korean adolescents aged 10–19 years (Korea National Statistical Office, 2013). Suicide and related behaviors among adolescents have become major public health concerns in Korea, and it is important to determine the risk factors associated with the suicidal behaviors of ideation, planning, and attempts. Psychological distress and psychosocial difficulties increase the risk of suicidal behaviors in adolescents (Vitiello and Pearson, 2008), and distorted weight perception is considered as a possible risk factor associated with suicidal behaviors (Kim and Lee, 2010).

In adolescence, the individual usually becomes increasingly autonomous, but also vulnerable. Skin diseases are noted in social interaction and affect self-esteem (Brown et al., 2013), and atopic dermatitis is a common visible skin disorder of adolescents. Individuals with atopic dermatitis are affected both by the condition itself and by the stigma associated with its visibility (Finlay, 2001). In addition, atopic dermatitis might induce mental health problems as well as changes in body image and lowered self-confidence that can result in poor academic and social development (Absolon et al., 1997). Impaired psychological and social functioning may lead to increased risk for suicide among adolescents (Evans et al., 2004). Although most previous studies have reported a higher prevalence of psychosocial and psychiatric comorbidity among patients with atopic dermatitis (Gupta and Gupta, 2003; Kelsay et al., 2010; Schmitt et al., 2009), there are few reports of the relationship between suicidal behaviors and atopic dermatitis, especially among adolescents. Moreover, there is a need to consider other risk factors, such as stress, depressive mood, sleep problems, and body weight perceptions, to clarify the association between suicidal behaviors and atopic dermatitis among adolescents. To the best of our knowledge, there is no study of the relationship between atopic dermatitis and suicidal behaviors after adjustment of related risk factors, including body weight perception, in a nationally representative sample of adolescents.

Therefore, we conducted this study to evaluate the relationship between atopic dermatitis and suicidal behaviors after considering various suicidal risk factors, including distorted weight perception, among Korean adolescents using data from a nationally representative survey.

Methods

Data and participants

This study is based on data from the Eighth Korea Youth Risk Behavior Web-Based Survey (KYRBWS-VIII) in 2012. The KYRBWS has been conducted annually since 2005 to assess the prevalence of adolescent health risk behaviors among Korean students from Grades 7 to 12. The KYRBWS-VIII is an anonymous, self-administered, national school-based survey conducted by the Korea Centers for Disease Control and Prevention (KCDC). A complex sample design, which included multistage sampling, stratification, and clustering, was used to obtain a nationally representative sample of middle and high school students.

Students participating in the survey were randomly assigned a unique identification number, which they used to log on to the survey’s Internet webpage in the computer room of their school. The survey consisted of 129 questions in 15 categories, including weight, mental health, allergic disorders, and health equity. A total of 76,980 students from 400 middle schools and 400 high schools were selected for the survey and the response rate was 96.4 percent. The final study participants included 74,186 students (38,221 boys and 35,965 girls). Additional details on the sampling methodology and survey procedure are available elsewhere (KCDC, 2012). This study was reviewed and approved by the Institutional Review Board (IRB approval number: 2014–20) of Chuncheon Sacred Heart Hospital.

Measures

From the KYRBWS-VIII questionnaire, we used variables including suicidal ideation, planning and attempts, atopic dermatitis, mental health status such as depressive mood and perceived stress, sleep satisfaction, self-reported weight and height, self-perceived weight, academic achievement, and socioeconomic status (SES).

Suicidal ideation, planning, and attempts were assessed via the following questions: “During the past 12 months, did you ever seriously think about suicide?”; “During the past 12 months, did you ever make a specific plan to commit suicide?”; and “During the past 12 months, did you ever attempt suicide?” respectively. The presence of atopic dermatitis was assessed via the following question: “In your life, have you ever been diagnosed with atopic dermatitis by a doctor?” Self-reported depressive mood was assessed for each adolescent by asking the following question: “During the past 12 months, did you ever feel so sad or hopeless for 2 weeks or more in a row that you stopped doing usual activities?” Responses to each question were restricted to “yes” or “no.”

Stress perception was measured by one question, “How much stress are you experiencing in your daily life?” Responses were rated on a 5-point Likert scale; the categories of 4 (high level of stress) or 5 (very high level of stress) were considered “high-stress” and all other responses were considered “low-stress” for analysis. With regard to the level of satisfaction experienced after sleeping, respondents answered the following question: “Did you feel refreshed after sleeping in the last week?” The 5-point Likert scale responses were collapsed into dichotomous categories; 5 (very good) and 4 (good) became “yes” and all others were “no.”

Height and body weight of adolescents were self-reported on the questionnaire. Body mass index (BMI) was calculated by dividing the body weight by the height squared (kg/m²). Obesity categories were defined using age- and gender-specific BMI percentiles based on the data from the Korean Pediatric Growth Chart (KCDC et al., 2007). Adolescents were classified into three groups based on weight: underweight (≤5th percentile), normal weight (5th–84th percentile), and overweight or obese (85th–94th percentile and ≥95th percentile). Weight perception was assessed by the following question: “How do you describe your weight?” The responses on the 5-point Likert scale were collapsed into three categories: underweight, involving 1 (very underweight) and 2 (slightly underweight); normal weight, 3; and overweight, involving 4 (slightly overweight) and 5 (very overweight). Distorted weight perception was defined as the discrepancy between the category of the participants’ weight perception and his or her actual weight category: correct weight (the two categories were the same), underestimation (perceived weight was lower than actual weight), or overestimation (perceived weight was higher category than actual weight category).

Socio-demographic information included grade in school, age, gender, academic achievement, SES, and family structure. Academic achievement was evaluated by asking the following question: “During the past 12 months, how would you describe your grades in school?” SES was assessed with the following question: “How would you rate your family’s socioeconomic status?” Academic achievement and SES were collapsed into three categories: high (high and upper middle), middle, and low (lower middle and low).

Statistical analysis

All analyses regarding the relationship between suicidal behaviors and independent factors, including atopic dermatitis, distorted weight perception, BMI category, depressive mood, perceived stress, sleep satisfaction, and socio-demographic characteristics were performed separately for each gender. Initially, chi-square tests were used to identify relationships between suicidal behaviors and these independent factors. Unadjusted logistic regression analysis was used to examine associations between atopic dermatitis and suicidal behaviors, including suicidal ideation, planning, and attempts. A multiple logistic regression analysis was conducted to control for the confounding effects of potential risk factors, such as school year, academic achievement, SES, family structure, distorted weight perception, sleep satisfaction, perceived stress, and depressed mood. We performed further analyses to evaluate the odds ratios (ORs) of suicidal behaviors according to the presence of atopic dermatitis, with participants without atopic dermatitis serving as the reference group, by each stratum for distorted weight perception.

All estimates were calculated based on sample weights, developed using the sampling rate, response rate, sex, school type, and grade proportions of the reference population. The analyses were adjusted for the complex sample design of the survey. All analyses were two-sided, and p-values of <0.05 were considered statistically significant. All statistical analyses were performed using IBM Statistical Package for Social Sciences (SPSS) Statistics 21 for the Medical Service Network (Chicago, IL, USA).

Results

Overall, 18.3, 6.3, and 4.1 percent of the subjects reported having suicidal ideation, planning, and attempts, respectively. The prevalence of atopic dermatitis was reported by 24.3 percent of adolescents. The average age of the subjects was 13.5 years (standard error (SE) = 0.01 years) for middle school group and 16.4 years (SE = 0.01 years) for high school group, respectively. Table 1 shows the gender differences observed in all variables examined in this study. Girls were significantly more likely than boys to report suicidal behaviors, atopic dermatitis, depressive mood, and greater stress and to overestimate their body weight (ps < 0.001). In contrast, boys were more likely than girls to report the higher levels of academic achievement and SES and satisfactory sleep, and to underestimate their body weight (ps < 0.001).

Table 1.

General characteristics of participants by gender.

Characteristics		Boys (n = 38,221)			Girls (n = 35,965)			p
		n	Weighted %	SE	n	Weighted %	SE
School year								0.779
Grade 7–9		19,283	48.7	1.4	18,014	49.4	1.5
Grade 10–12		18,938	51.3	1.4	17,951	50.6	1.5
Academic achievement								<0.001
High/upper middle		13,490	35.4	0.4	12,032	33.6	0.3
Middle		9,949	26.1	0.2	9,905	27.6	0.2
Lower middle/low		14,782	38.5	0.3	14,028	38.8	0.3
Socioeconomic status								<0.001
High/upper middle		12,583	33.4	0.5	9,699	27.7	0.5
Middle		17,185	44.7	0.3	17,699	48.9	0.3
Lower middle/low		8,453	21.9	0.3	8567	23.3	0.4
Family structure								0.296
Live with both parents		31,727	83.7	0.3	29,765	83.6	0.3
Live with one parent		5,258	13.5	0.3	5,091	13.8	0.3
Neither		1,236	2.8	0.1	1,109	2.6	0.1
BMI								<0.001
Underweight		2,258	6.2	0.1	2,081	5.9	0.1
Normal weight		29,676	79.6	0.2	28,574	82.1	0.2
Overweight/obese		5,295	14.2	0.2	4,345	12.0	0.2
Distorted weight perception								<0.001
Underestimation		11,402	30.5	0.3	5,754	16.5	0.2
Correct weight		18,759	50.5	0.3	18,367	52.2	0.3
Overestimation		7,068	19.0	0.2	10,879	31.3	0.3
Sleep satisfaction	Enough	12,797	33.2	0.4	8,374	23.2	0.3	<0.001
Perceived stress	Yes	13,340	34.8	0.3	18,026	49.6	0.4	<0.001
Depressed mood	Yes	9,722	25.5	0.3	13,023	36.0	0.3	<0.001
Suicidal ideation	Yes	5,332	14.1	0.2	8,303	22.9	0.3	<0.001
Suicidal planning	Yes	1,882	5.0	0.1	2,827	7.8	0.2	<0.001
Suicide attempts	Yes	1,062	2.8	0.1	1,956	5.4	0.1	<0.001
Atopic dermatitis	Yes	8,033	21.2	0.2	9,938	27.8	0.3	<0.001

SE: standard error; BMI: body mass index.

The relationships between suicidal behaviors and atopic dermatitis and other characteristics stratified by gender are presented in Tables 2 and 3. Regardless of gender, subjects who reported the lower levels of academic achievement and SES, living without parents, unsatisfactory sleep, depressive mood, and greater perception of stress were more likely to report suicidal ideation, planning, and attempts (ps < 0.001). Moreover, distorted weight perception, such as underestimation or overestimation, was significantly associated with suicidal ideation, planning, and attempts for both genders. Girls with atopic dermatitis were significantly more likely to report suicidal ideation, planning, and attempts (ps < 0.001), whereas boys with atopic dermatitis tended to report suicidal ideation, but not suicidal planning and attempts.

Table 2.

Factors associated with suicidal ideation, planning, or attempts in Korean adolescent boys.

Characteristics	Suicidal ideation			Suicidal planning			Suicide attempts
	Weighted %	SE	p	Weighted %	SE	p	Weighted %	SE	p
School year			0.342			<0.001			0.053
Grade 7–9	13.9	0.3		5.6	0.2		3.0	0.1
Grade 10–12	14.2	0.3		4.4	0.2		2.6	0.1
Academic achievement			<0.001			<0.001			<0.001
High/upper middle	12.2	0.3		4.2	0.2		2.4	0.1
Middle	12.6	0.3		4.1	0.2		2.0	0.2
Lower middle/low	16.8	0.3		6.2	0.2		3.7	0.2
Socioeconomic status			<0.001			<0.001			<0.001
High/upper middle	13.1	0.3		5.0	0.2		2.7	0.2
Middle	11.7	0.3		4.0	0.2		2.1	0.1
Lower middle/low	20.3	0.5		6.9	0.3		4.3	0.2
Family structure			<0.001			<0.001			<0.001
Live with both parents	13.4	0.2		4.7	0.1		2.6	0.1
Live with one parent	16.3	0.5		5.4	0.3		3.4	0.3
Neither	22.6	1.3		9.9	1.0		7.3	0.8
BMI			0.206			0.042			0.654
Underweight	13.7	0.7		5.3	0.5		2.9	0.4
Normal weight	13.6	0.2		4.6	0.1		2.6	0.1
Overweight/obese	14.6	0.5		5.2	0.3		2.7	0.2
Distorted weight perception			<0.001			0.016			0.029
Underestimation	14.4	0.4		5.1	0.2		2.8	0.2
Correct weight	12.9	0.3		4.4	0.2		2.4	0.1
Overestimation	15.1	0.4		4.9	0.3		3.0	0.2
Sleep satisfaction			<0.001			<0.001			<0.001
Not enough	16.7	0.3		5.8	0.2		3.4	0.1
Enough	8.8	0.3		3.2	0.2		1.6	0.1
Perceived stress			<0.001			<0.001			<0.001
Yes	28.0	0.4		10.1	0.3		5.7	0.2
No	6.6	0.2		2.2	0.1		1.3	0.1
Depressed mood			<0.001			<0.001			<0.001
Yes	36.5	0.5		13.7	0.4		8.0	0.3
No	6.4	0.2		2.0	0.1		1.0	0.1
Atopic dermatitis			0.006			0.578			0.739
Yes	15.1	0.4		4.8	0.3		2.9	0.2
No	13.8	0.2		5.0	0.2		2.8	0.1

SE: standard error; BMI: body mass index.

Table 3.

Factors associated with suicidal ideation, planning, or attempts in Korean adolescent girls.

Characteristics	Suicidal ideation			Suicidal planning			Suicidal attempts
	Weighted %	SE	p	Weighted %	SE	p	Weighted %	SE	p
School year			0.012			<0.001			<0.001
Grade 7–9	23.6	0.4		9.3	0.3		6.4	0.2
Grade 10–12	22.2	0.4		6.3	0.2		4.5	0.2
Academic achievement			<0.001			<0.001			<0.001
High/upper middle	19.1	0.4		6.4	0.3		4.0	0.2
Middle	19.7	0.4		6.0	0.3		4.1	0.2
Lower middle/low	28.5	0.4		10.2	0.3		7.6	0.2
Socioeconomic status			<0.001			<0.001			<0.001
High/upper middle	20.4	0.5		7.3	0.3		5.0	0.2
Middle	20.1	0.3		6.4	0.2		4.5	0.2
Lower middle/low	31.8	0.6		11.3	0.4		7.9	0.3
Family structure			<0.001			<0.001			<0.001
Live with both parents	21.6	0.3		7.0	0.2		4.8	0.1
Live with one parent	28.0	0.7		10.5	0.5		7.6	0.4
Neither	37.2	1.6		18.3	1.4		13.9	1.3
BMI			<0.001			<0.001			0.268
Underweight	19.3	0.9		6.2	0.6		4.4	0.5
Normal weight	22.4	0.3		7.3	0.2		5.2	0.2
Overweight/obese	25.2	0.7		8.9	0.4		5.3	0.3
Distorted weight perception			<0.001			<0.001			<0.001
Underestimation	23.5	0.6		8.1	0.4		5.6	0.3
Correct weight	20.6	0.3		6.6	0.2		4.6	0.2
Overestimation	25.3	0.5		8.4	0.3		6.0	0.3
Sleep satisfaction			<0.001			<0.001			<0.001
Not enough	25.4	0.3		8.6	0.2		6.1	0.2
Enough	14.7	0.4		4.9	0.2		3.4	0.2
Perceived stress			<0.001			<0.001			<0.001
Yes	36.6	0.4		13.0	0.3		8.9	0.2
No	9.5	0.2		2.6	0.1		2.0	0.1
Depressed mood			<0.001			<0.001			<0.001
Yes	45.5	0.5		16.7	0.4		11.8	0.3
No	10.2	0.2		2.7	0.1		1.8	0.1
Atopic dermatitis			<0.001			<0.001			<0.001
Yes	25.2	0.5		9.1	0.3		6.3	0.3
No	22.0	0.3		7.2	0.2		5.1	0.1

SE: standard error; BMI: body mass index.

The relationship of atopic dermatitis with suicidal behaviors is presented in Table 4. Compared with girls without atopic dermatitis, the crude ORs of suicidal ideation, planning, and attempts for girls with atopic dermatitis were 1.195 (95% confidence interval (CI): 1.132–1.261), 1.292 (95% CI: 1.186–1.409), and 1.240 (95% CI: 1.120–1.374), respectively. Atopic dermatitis was associated with suicidal ideation for boys, but not with suicidal planning and attempts. For girls, the association between atopic dermatitis and suicidal behaviors remained significant after adjustments for multiple confounding factors including school year, academic achievement, SES, family structure, distorted weight perception, sleep satisfaction, perceived stress, and depressed mood (OR = 1.114, 95% CI: 1.046–1.186; OR = 1.228, 95% CI: 1.120–1.345; and OR = 1.188, 95% CI: 1.065–1.325, respectively). In the same models, no significant associations between atopic dermatitis and suicidal behaviors were observed in boys.

Table 4.

Odds ratios and 95% confidence interval for suicidal ideation, planning, or attempts according to atopic dermatitis in Korean adolescents.

	Boys				Girls
	Model 1		Model 2		Model 1		Model 2
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Suicidal ideation
With atopic dermatitis	1.107	1.030–1.191	1.042	0.961–1.130	1.195	1.132–1.261	1.114	1.046–1.186
Without atopic dermatitis	1	Referent	1	Referent	1	Referent	1	Referent
Suicidal planning
With atopic dermatitis	0.967	0.859–1.088	0.885	0.777–1.007	1.292	1.186–1.409	1.228	1.120–1.345
Without atopic dermatitis	1	Referent	1	Referent	1	Referent	1	Referent
Suicidal attempts
With atopic dermatitis	1.027	0.880–1.199	0.949	0.800–1.124	1.240	1.120–1.374	1.188	1.065–1.325
Without atopic dermatitis	1	Referent	1	Referent	1	Referent	1	Referent

OR: odds ratio; CI: confidence interval.

Model 1: not adjusted.

Model 2: adjusted for school year, academic achievement, socioeconomic status, family structure, distorted weight perception, sleep satisfaction, perceived stress, and depressed mood.

The joint effect of atopic dermatitis and distorted weight perception in girls was examined; girls with atopic dermatitis and overestimation of weight perception had the highest risk of suicidal ideation, planning, or attempts (Table 5). Among girls without distorted weight perception, atopic dermatitis was significantly associated with only suicidal planning (OR = 1.330; 95% CI: 1.166–1.516). For girls who underestimated their weight, atopic dermatitis was associated with suicidal ideation (OR = 1.208; 95% CI: 1.039–1.405), but not with suicidal planning and attempts. In girls who overestimated their weight, atopic dermatitis had a strong association with suicidal ideation (OR = 1.125; 95% CI: 1.009–1.253), planning (OR = 1.190; 95% CI: 1.022–1.385), and attempts (OR = 1.353; 95% CI: 1.139–1.607).

Table 5.

Odds ratios and 95% confidence interval for suicidal ideation, planning, or attempts by distorted weight perception and atopic dermatitis in Korean adolescent girls.

	Underestimation			Correct weight			Overestimation
	OR	95% CI	p	OR	95% CI	p	OR	95% CI	p
Suicidal ideation	1.208	1.039–1.405	0.014	1.072	0.984–1.168	0.113	1.125	1.009–1.253	0.033
Suicidal planning	1.047	0.835–1.313	0.691	1.330	1.166–1.516	<0.001	1.190	1.022–1.385	0.025
Suicidal attempts	1.241	0.949–1.623	0.114	1.043	0.891–1.222	0.597	1.353	1.139–1.607	0.001

OR: odds ratio; CI: confidence interval.

Results are adjusted for school year, academic achievement, socioeconomic status, family structure, sleep satisfaction, perceived stress, and depressed mood.

Discussion

The aim of this study was to evaluate the association of atopic dermatitis and suicidal behaviors among adolescents. Although previous studies have shown that suicidal ideation was highly prevalent in patients with atopic dermatitis (Picardi et al., 2013), they did not consider body weight perception and mostly targeted adults. In this study, based on a nationally representative sample of Korean adolescents, we found that atopic dermatitis increased the risk of suicidal behaviors in girls in the 7th–12th grade even after adjustments for multiple confounding factors, including psychological status, body weight perception, academic achievement, and SES. These relationships between atopic dermatitis and suicidal behaviors were true especially in girls with overestimation of weight perception. In the boys with atopic dermatitis, however, there were no significant relationships between atopic dermatitis and suicidal ideation, planning, and attempts.

One attempted suicide substantially increases the risk of further attempts and of suicidal death (Vitiello and Pearson, 2008). Although most suicide attempts are not successful, suicidal behaviors, such as suicidal ideation and attempt, remain the most significant predictor of future psychopathology and completed suicide (Bridge et al., 2006). Thus, a comprehensive evaluation and in-depth assessment of suicidal behaviors are essential to prevent completed suicides among adolescents. The statistical association between the multiple variables and suicide behaviors among adolescents was demonstrated; however, the predictive power of each risk factor in isolation was low (Vitiello and Pearson, 2008). Risk factors are likely to be intercorrelated and, therefore, the combination of multiple variables increases or decreases the risk of suicidal behaviors (Vitiello and Pearson, 2008). It is crucial that adolescents at high risk for suicidal behaviors be identified; this is a necessary step toward preventing repeated suicide attempts and completed suicides.

Several studies have reported a high prevalence of suicidal ideation in patients with atopic dermatitis. A Danish study showed a higher prevalence of suicidal thoughts (18.9% in patients with atopic dermatitis compared with 6.8% in healthy controls) (Zachariae et al., 2004). In a Japanese study, lifetime prevalence of suicidal ideation was 19.6 percent in patients with severe atopic dermatitis and 8.1 percent among 3,575 healthy controls (Kimata, 2006). On the other hand, a previous study found a relatively low prevalence of suicidal ideation in patients with atopic dermatitis when compared with a prevalence of 4 percent in dermatology patients as a group (Gupta and Gupta, 1998).

The results of this study showed that 18.3 and 4.1 percent of adolescents reported having suicidal ideation and attempts in the previous year. This prevalence is similar to that of a previous systematic review showing that 19.3 and 6.4 percent of adolescents had suicidal thoughts and attempts in the previous year (Evans et al., 2005). In a cross-sectional study among Taiwanese adolescents, 17.5 percent of the participants reported having suicidal ideation during the past 12 months (Wang et al., 2011), which is comparable to our result. In addition, suicidal behaviors are clearly more common in girls than in boys. This gender difference is also similar to that of previous studies (Eaton et al., 2012; Evans et al., 2005; Wang et al., 2011). This rate is in contrast to completed suicides, where young females have lower rates than males (Bridge et al., 2006). The results of our study revealed that girls reported greater depressive moods, stress, and unsatisfactory sleep than boys. Girls were more likely to overestimate their body weight than boys were, and more tended to report lower levels of academic achievement and SES. The gender difference was also observed in the association between atopic dermatitis and suicidal behaviors. Girls might be more likely to suppress emotions in the cultural aspects, which characteristically results in low self-esteem and sense of control. Girls tend to display internalized symptoms and not to express problematic emotions, allowing negative feelings to be directed toward the self. Some factors related to the gender difference found in this study may explain the increasing prevalence and risk of suicidal behaviors in girls; these require further study.

The mechanisms by which atopic dermatitis increases the risk of suicidal behaviors are unclear. Atopic dermatitis is a chronic relapsing skin disease that is characterized by pruritic eczema. Atopic dermatitis and psychological stress form a vicious cycle (Hashizume and Takigawa, 2006), and atopic dermatitis has been associated with psychological comorbidities, including depression, anxiety, and sleep disturbance (Gupta and Gupta, 2003). Such psychological factors are also linked to suicidal behaviors among adolescents; therefore, psychological comorbidities might mediate the relationship between atopic dermatitis and suicidal behaviors. However, our study results were adjusted for psychological factors related to suicide, suggesting potential alternative pathways by which atopic dermatitis contributes to suicidal behaviors, such as physiologic changes in atopic dermatitis. Several laboratory studies reported that adrenocortical response to stress in children with atopic dermatitis is blunted compared with healthy controls (Buske-Kirschbaum et al., 1997, 2002), which could make the patients more fragile and vulnerable to physiologic changes in stressful situations, thus increasing the risk of suicidal behaviors. Cytokines may contribute to the development or aggravation of depressive moods in patients with atopic dermatitis. Several mechanisms have been suggested to explain how cytokines may affect brain function and behavior. Interleukin-4 has an effect on the serotonin metabolism (Mossner et al., 2001), and cytokines can induce activation of the hypothalamic–pituitary–adrenal axis, resulting in altered levels of corticotropin-releasing hormone and cortisol, which have detrimental effects for neurons (Turnbull and Rivier, 1999). Direct interactions between brain cells and cytokines also have been proposed (Tonelli et al., 2005). The imbalance of cytokine expression in the brain may affect neuronal function in response to inflammatory processes initiated in the periphery (Postolache et al., 2008).

The results of our study also found that distorted weight perception was associated with suicidal behaviors. This finding was consistent with studies conducted by Eaton et al. (2005) and Kim and Lee (2010) with American and Korean adolescents. Interestingly, in this study, atopic dermatitis was associated with a greater risk of suicidal behaviors for girls who overestimated their weight. This suggests that atopic dermatitis and distorted weight perception, especially overestimation, seem to have additive influences on suicidal risk. Body image concerns are likely to be much greater in women, especially in the adolescents, independent of their dermatologic disorder. Girls usually have greater concerns on outward appearance and attractiveness and could be more affected by responses from peers. Adolescents with atopic dermatitis, especially those with visible lesions, would be more likely to experience personal rejection and to have cutaneous body image dissatisfaction as well as distorted body image. These factors could result in social disapproval, social withdrawal, bullying, psychological problems, self-injury, and suicide (Gupta and Gupta, 2013).

The present study has several limitations. First, the cross-sectional nature of the data limited our ability to make inferences about causal relationships between atopic dermatitis and suicidal behaviors. Second, the survey was conducted in schools and data were collected by self-report questionnaires. Peer groups may have influenced students’ replies to some sensitive questions, including those about suicidal behaviors and psychosocial factors; therefore, some information bias cannot be ruled out. In addition, there could be misclassification in the distorted weight perception and recall bias in the prevalence of atopic dermatitis. The distortion of weight perception was assessed by self-reported weight and height, and this could influence the accuracy of the data and this variable. Adolescents who overestimated their weight may be more likely to underreport their weight, and those who were actually obese may also underreport weight. Third, only the lifelong diagnosis of atopic dermatitis among adolescents was evaluated in this study. We did not analyze the treatment modality and the severity of atopic dermatitis because of the lack of such information in the secondary data analyzed. Furthermore, the survey did not assess other significant factors associated with suicidal behaviors, such as personality, exposure to suicide in the community or the media, family history of suicide, and genetic factors. Finally, the strength of the relationships between atopic dermatitis and suicidal behaviors could be clinically weak, although the relationships were significant even after adjustment for multiple confounding factors. However, as more than one in four Korean adolescent girls reported having atopic dermatitis and almost half of the total sample of girls revealed distorted body perception, the absolute number of adolescent girls with a risk for suicide is significant, even though the strength of associations was not remarkable. Despite these limitations, our study has some strengths. The survey was conducted recently in a large nationwide representative sample of Korean adolescents, and all analyses in this study were based on sample weights and adjusted for the complex sample design of the survey. Thus, these results can be generalized for the entire Korean adolescent population. In addition, there is little information on the influence of body weight perception, atopic dermatitis, and suicidal behaviors among adolescents, and this study may be the first report of the relationship between atopic dermatitis and suicidal behaviors after adjustment of related risk factors, including body weight perception, in a nationally representative sample of Korean adolescents.

In conclusion, this study demonstrates that atopic dermatitis is an independent risk factor for suicidal behaviors in Korean adolescent girls, and the overestimation of weight perception appeared to have an additive impact on suicidal risk among girls with atopic dermatitis. The results of this study suggest that the physicians should increase their awareness of suicide and mental health, including body weight perception, in adolescents with atopic dermatitis.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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