Research Highlights the Importance of Screening Patients for Alcohol Use Disorder

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Research overwhelmingly indicates a link between chronic skin conditions, including pigmentary disorders, and poor mental health, including negative self-identity, social stigmatization, anxiety, and clinical depression.¹ For example, a systematic review of observational studies and clinical trials found that, in addition to depression and anxiety, patients with vitiligo experience psychosocial comorbidities that result in decreased quality of life (QOL), including stigmatization, adjustment disorders, sleep disturbance, relationship difficulties (including sexual dysfunction), and avoidance or restriction behavior.²

Another systematic literature review of peer-reviewed observational and interventional studies noted vitiligo had moderate or worse effects on patients’ QOL.³ QOL was likewise found to be negatively impacted in patients with psoriasis, with 1 study finding levels comparable with what is reported by patients with cancer, myocardial infarction, and heart failure.⁴

Higher rates of anxiety and depression have also been found across multiple inflammatory skin diseases (psoriasis, atopic dermatitis, acne) and pigmentary disorders.^5,6 Specifically, anxiety disorder and depression prevalence in patients with melasma, vitiligo, and acquired dermal macular hyperpigmentation was 11.6% and 12.8%, 21% and 27%, and 18.7% and 24.1%, respectively.⁶

Examining the Association

Given the association of anxiety and depression with alcohol use disorder (AUD) and the association of anxiety and depression with dermatological disorders,⁷ there is an interest in better understanding the relationship between dermatological disease and AUD, as well as the relative influence of depression and anxiety. Thus, Kamal et al investigated whether comorbid depression and anxiety mediate a relationship between AUD and skin disease.⁸

Utilizing the National Institutes of Health’s All of Us Research Program, Kamal et al identified patients with chronic dermatologic diseases that are associated with mental health comorbidities including depression, anxiety, and AUD (pigmentary disorders [vitiligo, melasma, postinflammatory hyperpigmentation], atopic dermatitis, acne, rosacea, alopecia areata, hidradenitis suppurativa, and psoriasis). The investigators performed 2 multivariate adjusted logistic regression analyses and calculated the number needed to screen (NNS) to identify AUD in patients with dermatological disease alone vs those with dermatologic disease and comorbid anxiety and/or depression. More than 65,000 dermatological disease cases were included in the analysis.

The authors found that, compared with patients who did not have dermatological diseases or depression/anxiety, there were increased odds of AUD in patients with pigmentary disorders, atopic dermatitis, acne/rosacea, hidradenitis suppurativa, and psoriasis. Furthermore, the authors found a significantly increased odds of AUD in patients with depression/anxiety who had comorbid atopic dermatitis, acne/rosacea, and psoriasis when compared with patients who only had depression/anxiety. These conclusions are consistent with previous studies that identified an increased risk of AUD with dermatological disease mediated by psychiatric disorders such as anxiety and depression. However, the current study highlighted the additive effect of comorbid dermatological and psychiatric disease on the prevalence of AUD.

Interestingly, the NNS for AUD across all dermatological disease dropped when patients had comorbid depression or anxiety. The study found that the odds of AUD were significantly higher in patients with comorbid skin and psychiatric disorders when compared with patients with depression and anxiety alone.

The authors found the odds of AUD were 1.37 (1.24–1.52; P < .001) for patients with pigmentary disorders when compared with patients who did not have dermatological disease and anxiety/depression. Similarly, the mediation of depression and anxiety on total AUD risk was 75% for pigmentary disorders. The NNS to identify AUD in patients with pigmentary disorders was 32 but decreased by 3 to 4 for patients with comorbid depression and anxiety.

Interestingly, the association between AUD and dermatological disease was strongly mediated by depression and anxiety across all dermatological disorders studied except hidradenitis suppurativa. However, patients with hidradenitis suppurativa had the highest absolute risk for AUD and the lowest NNS to identify AUD. There may be a few reasons for this finding. One likely explanation is that, in addition to adverse psychological effects, patients with hidradenitis suppurativa have severe physical symptoms such as pain, drainage, and repeated infections, which may be driving the increased AUD prevalence.⁹

There are some limitations to the study. Kamal et al used objective electronic health record diagnostic coding to define AUD, as opposed to self-reported survey data. Although International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision coding for the classification and accuracy of identifying AUD is considered best practice, cases may be missed.¹⁰ Furthermore, the possibility of reverse causality cannot be ruled out given the sequence of dermatologic disease, depression, anxiety, and AUD due to the cross-sectional nature of the study design. Finally, the authors only evaluated comorbid depression and anxiety, but there are other documented psychiatric and dermatologic comorbidities, such as obsessive-compulsive disorder, posttraumatic stress disorder, and attention-deficit/hyperactivity disorder.¹¹ The authors suggested that further studies should investigate the role that these comorbidities, among others, play in prevalence of AUD and other substance use disorders.

The Role of Psychological Burden

Figure

The findings in the Kamal et al study add to the existing literature on the secondary negative sequelae of dermatologic disease. Although there is a misperception that dermatologic disease is just a “cosmetic problem,” data have demonstrated that patients with dermatologic diseases have significant negative secondary psychological effects. These secondary effects can lead to a large impact on QOL and could even lead to self-harm or suicide.

It has been well established that cutaneous disease can carry a large psychological burden. For example, an international, multicenter, observational, cross-sectional case-controlled study (N=4994; 3635 patients and 1359 controls) conducted in 13 European countries examined the rates of depression, anxiety, and suicidal ideation among patients with various dermatological diagnoses. Overall, the prevalence of clinical depression, anxiety, and suicidal idea was 10.1%, 17.2%, and 12.7%, respectively (Figure).¹² In addition, suicide ideation was only statistically significant for patients with psoriasis, and the association of anxiety and depression was highest for patients with psoriasis, atopic dermatitis, hand eczema, and leg ulcers.

It is also well established that AUD and depression are prevalent in society and are often comorbid conditions. In fact, depressive disorders are the most common psychiatric disorder among patients with AUD.¹³ Furthermore, the co-occurrence of these disorders can result in greater severity of each disorder and a worse prognosis when compared with each disease state alone.¹⁴ Additional research has also shown that up to 50% of patients receiving treatment for AUD also met diagnostic criteria for 1 or more anxiety disorders.¹⁵

Despite these well-established associations, the relationship between dermatologic disease and AUD as well as the relative contribution of depression and anxiety to that relationship has not been well characterized. However, it is not surprising that Kamal et al found increased odds of AUD among patients with pigmentary and other dermatological disorders given the association with negative secondary psychological effects. This relationship was partially mediated and exacerbated by anxiety and depression, with the dermatologic diseases having the most visible disfiguring components having the greatest impact of depression and anxiety on AUD.

Just as alcohol and other substances may be used by patients to lessen the impact of depressive symptoms,¹⁶ alcohol may be used as a coping strategy for those with dermatological diseases leading to higher rates of AUD. For example, according to one study, 15% of patients with vitiligo were addicted to alcohol.¹⁷ In another study, researchers using data from the 2015 to 2019 Nationwide Emergency Department Sample found vitiligo was associated with AUD with an adjusted odds ratio of 1.88 (95% CI, 1.68–2.11).¹⁸

Implementing AUD Screening

Given that pigmentary dermatologic diseases are associated with an increased absolute risk and the odds of AUD are partially mediated by anxiety and depression, dermatology clinicians should be vigilant in screening for and identifying these comorbidities during evaluation and routine follow-up visits. This is especially important because many times the dermatologist may be the only physician a patient is seeing. For example, in a retrospective cohort study using a database representing 12 million to 14 million individuals in the United States, approximately one-third of men and one-quarter of women had no primary care visits in the year after they initiated care with their dermatologist.¹⁹

Fortunately, screening for AUD and depression can be easily completed in the office by dermatological clinicians using the 10-question Alcohol Use Disorders Identification Test and the 2-question Patient Health Questionnaire for depression.^20,21

Clinicians, especially those who see patients with inflammatory and pigmentary disorders, should incorporate these screening measures into all patient visits/encounters to ensure patients with psychiatric diseases or substance use disorders receive appropriate referrals and timely treatment, which will ultimately improve patient care and outcomes.

Nicholas Brownstone, MD, is a dermatology resident at Temple University Hospital in Philadelphia, Pennsylvania.

References

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