572453 research-article2015
HPQ0010.1177/1359105315572453Journal of Health PsychologyNoh et al.
Article
The relationship between suicidal behaviors and atopic dermatitis in Korean adolescents
Journal of Health Psychology 1–12 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105315572453 hpq.sagepub.com
Hye-Mi Noh, Jung Jin Cho, Yong Soon Park and Jeong-Hyeon Kim
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 Hallym University College of Medicine, Korea Corresponding authors: Jung Jin Cho, Department of Family Medicine, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 445-907, Korea. Email: [email protected] Yong Soon Park, Department of Family Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon, Gangwondo 200-704, Korea. Email: [email protected]
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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, selfadministered, 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.
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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 genderspecific 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 sociodemographic 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
Downloaded from hpq.sagepub.com at UNIV NEBRASKA LIBRARIES on September 28, 2015
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Journal of Health Psychology
depressive mood, and greater perception of stress were more likely to report suicidal ideation, planning, and attempts (ps
HPQ0010.1177/1359105315572453Journal of Health PsychologyNoh et al.
Article
The relationship between suicidal behaviors and atopic dermatitis in Korean adolescents
Journal of Health Psychology 1–12 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105315572453 hpq.sagepub.com
Hye-Mi Noh, Jung Jin Cho, Yong Soon Park and Jeong-Hyeon Kim
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 Hallym University College of Medicine, Korea Corresponding authors: Jung Jin Cho, Department of Family Medicine, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 445-907, Korea. Email: [email protected] Yong Soon Park, Department of Family Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon, Gangwondo 200-704, Korea. Email: [email protected]
Downloaded from hpq.sagepub.com at UNIV NEBRASKA LIBRARIES on September 28, 2015
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Journal of Health Psychology
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, selfadministered, 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.
Downloaded from hpq.sagepub.com at UNIV NEBRASKA LIBRARIES on September 28, 2015
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Noh et al.
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 genderspecific 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 sociodemographic 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
Downloaded from hpq.sagepub.com at UNIV NEBRASKA LIBRARIES on September 28, 2015
4
Journal of Health Psychology
depressive mood, and greater perception of stress were more likely to report suicidal ideation, planning, and attempts (ps
