Dermatología Pediatrica

Atopic dermatitis in adolescent boys is associated with greater psychological morbidity compared with girls of the same age: the Young-HUNT study

• M. Saunes,
• I. Smidesang**Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway,
• T.L. Holmen*†*Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway†HUNT Research Centre, Verdal, Norway and
• R. Johnsen**Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway

• Department of Dermatology, St Olavs Hospital, Trondheim University Hospital, Eirik Jarls gt. 12, N-7006 Trondheim, Norway
  *Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
  †HUNT Research Centre, Verdal, Norway

Summary

Background Having atopic dermatitis (AD) as well as other chronic diseases is often associated with reduced mental health. Adolescents with AD are thought to be especially vulnerable, but few studies have included an ample number of young people.

Objectives To study self-reported mental distress among boys and girls 13-19 years of age with AD compared with mental distress among healthy adolescents as well as mental distress among adolescents with other chronic diseases or complaints, such as headache, neck or shoulder pain, asthma, allergy and rhinitis.

Methods The Young-HUNT study was conducted as a cross-sectional, population-based survey in 1995-97. All students in Nord-Trondelag County, Norway, aged 13-19 years were invited, and some 89% participated. A questionnaire on mental and somatic health, life-style and social conditions was completed during one school hour.

• ResultsA total of 4384 girls and 4433 boys participated. The prevalence of mental distress was higher among older teenagers, and more than every fourth girl aged 17-19 reported mental distress. Although more girls than boys reported mental distress, AD, headache and neck or shoulder pain, the odds for reporting both AD and mental distress were higher for boys [odds ratio (OR)=21 (16-29)] compared with girls [OR=13 (11-16)]. A corresponding sex difference in reporting mental distress was also seen for some other chronic diseases or complaints.

Conclusions In adolescents aged 13-19 years there was a strong and significant association between self-reported mental distress and AD as well as headache and neck or shoulder pain for both sexes. Although boys reported fewer complaints as AD, they perceived the complaints a heavier burden than did the girls.

Atopic dermatitis (AD) is one of the most common skin disorders in the western world although the prevalence of the disease varies considerably between different countries.¹ Some of the highest symptom prevalence rates are recorded in Scandinavian countries.²⁵ It is mainly a disease of childhood, but older patients are also affected.^1,6 In most studies, AD affects more girls than boys.²⁴

The associations between having a chronic dermatological disease and reduced health-related quality of life (HRQL) as well as increased anxiety and depression are described in several studies.⁷⁹ Some have specifically considered mental health and AD, and all are consistent in finding an association between AD and reduced mental health.¹⁰¹² Age groups studied varies; however, none of them include an ample group of adolescents.

The impact of having a chronic illness or disease through the teenage period has been said by several authors to include aspects of physical effects, emotional and mental health as well as social, educational and vocational aspects.¹³¹⁵

The main objective was to study the association between AD and accompanying mental distress in adolescents, and to compare this association with reported mental distress among adolescents with other chronic diseases and complaints, as well as to healthy individuals.

Materials and methods

The Young-HUNT study is the youth part of the HUNT [Nord-Trondelag Health Study, http://www.medisin.ntnu.no/hunt/ (accessed 30 October 2006)] study conducted from 1995 to 1997, as a cross-sectional study. All students aged 13-19 years living in Nord-Trondelag County (located in central Norway) were invited, and the participation rate was 89%. A self-reported questionnaire was completed during one school hour, including questions on mental and somatic health, quality of life and life-style. Questions on eczema, asthma and rhinitis were from The International Study of Asthma and Allergies in Childhood (ISAAC).¹

AD was defined as a 'Yes' answer to all three questions: 'Have you ever had an itchy rash that has lasted at least 6 months?', 'Have you had this rash during the last 12 months?' and 'Was the rash ever located on any of the following places: elbows (on the crease side), behind the knee, in front of the ankles, under the buttocks, or around the neck, ears or eyes?'

Asthma was defined as a 'Yes' answer to both questions: 'Have you had wheezing or whistling in the chest during the last 12 months?' and 'Has your physician ever told you that you have asthma?' Allergy was defined as a 'Yes' answer to both 'Do you have any allergies?' and 'Have you had any allergy test prescribed by your physician?' Rhinitis was defined as a 'Yes' answer to the two questions on allergy as well as 'Yes' to the question: 'Have you ever had problems with sneezing and/or a clogged or runny nose when you DO NOT have a cold or the flu?'

As a measure of mental distress, the Symptom Check List (SCL)-5 was included in the Young-HUNT questionnaire. SCL-5 covers two dimensions, namely depression and anxiety.¹⁶ It consists of five questions on a four-point scale ranging from 1 = 'not at all' to 4 = 'extremely'. All five questions are related to the last 2 weeks. To get the total SCL-5 score, the average item score is calculated by dividing the total score by the number of items answered.

• For descriptive purposes, the answer categories of all five questions were dichotomized into no/a little and quite/very (Table1). If any of the five questions were not answered, the person was excluded from the final analysis. The SCL-5 cut-off value was set to 20 compared with the conventional 175 for the SCL-25.^16,17

The aim was also to compare mental distress in adolescents with AD with mental distress in those with other chronic diseases or complaints as well as with a group of healthy individuals. As other diseases or complaints we included headache, neck or shoulder pain, asthma, allergy and rhinitis.

Headache and neck or shoulder pain were reported by the questions: 'Have you had any of these ailments during the last 12 months: headache (without known medical cause) and neck or shoulder pain?' The response categories were 'never', 'seldom', 'sometimes' and 'often'. The answers were dichotomized into 'never/seldom/sometimes' and 'often'.

Students with AD, headache, neck or shoulder pain, asthma, allergy or rhinitis were compared with students not reporting any of these complaints. These students we defined as being healthy.

Ethics

The study was approved by the Regional Committee of Ethics and the Norwegian Data Inspectorate. Each student signed a written consent to participate in the study. Parents of students < 16 years of age also gave their written consent.

Statistics

• All data were analysed using the Statistical Package for Social Science version 10.0 (SPSS Inc., Chicago, IL, U.S.A.) Univariate associations between reported mental distress and complaints were analysed using cross-tabulation, and for the χ² tests the level of significance was set to P<005. Logistic regression models were used to study the associations between mental distress and complaints in sex-specific analysis and in saturated models adjusted for sex and age, all other reported complaints, and for interaction between AD and sex. The Hosmer and Lemeshow test was used to test the multivariate model's goodness of fit. Confidence intervals (95% CI) were estimated for binominal distributed data.

Results

A total of 4384 girls (2970 aged 13-16 years and 1414 17-19 years) and 4433 boys (2964 aged 13-16 years and 1469 17-19 years), 89%, answered the studied items. The number of missing answers varies throughout the analysis; however, the proportion of missing answers on each question never exceeded 5%.

The older teenagers of both sexes reported more symptoms of mental distress (Table 1).

Girls experienced all five symptoms more frequently than boys. Feeling blue was reported three times more often among girls than boys. In both sexes 'feeling hopeless about the future', 'feeling blue' and 'worrying too much about things' were the most prevalent reported symptoms. For those reporting mental distress in the last 2 weeks there was a remarkable and significant difference between the age groups, especially among girls (Table 2). More than every fourth girl aged 17-19 years reported mental distress.

The difference between the age groups in reporting AD was small and insignificant for both girls and boys, while twice as many girls reported AD compared with boys (Table 2). Also for other complaints there was consistent girl preponderance in reporting mental distress (data not shown). Older female students with AD reported more mental distress than younger ones (Table 3). A corresponding age difference was not seen for boys with AD.

The higher proportion of older teenagers reporting mental distress was also mirrored among students with different diseases and disorders, as well as among their healthy fellow students (Table 3). AD was far from being perceived as the most distressing complaint, as nearly half of the oldest girls with headache and neck or shoulder pain reported symptoms of mental distress.

Although the absolute risks for reporting mental distress according to different diseases and complaints were age-dependent, the odds ratios were not (Table 4). There was a strong and consistent association between having neck or shoulder pain or headache and self-reported mental distress for both sexes.

• Of those having AD, 158% of girls reported headache and 132% neck or shoulder pain. For boys with AD the numbers were 71% and 45%, respectively.
• The association between AD and mental distress for girls 13-16years was significant with OR=15 (11-19) and correspondingly for girls 17-19years, with OR=15 (11-21). For boys of the same age the estimates were OR=26 (17-38) and OR=21 (13-34), respectively. The differences between the sexes were statistically significant only for age group 13-16years, P=003.
• In the adjusted model (Table5) the associations between reporting mental distress and other diseases or disorders were strongest for headache and neck or shoulder pain. The association was also strongest for boys regarding AD, headache and neck or shoulder pain. In the saturated model with sex as the independent variable, the interaction term between AD and sex was significant, supporting a stronger association between AD and mental distress for boys compared with girls. The model fitted well to the data as Hosmer and Lemeshow goodness of fit revealed χ²=24 and P=079 for girls and χ²= 384 and P=043 for boys. In contrast to those with complaints and diseases the healthy teenagers reported far less mental distress, and the risk of reporting mental distress was reduced by 50% compared with those who were not defined as healthy.

Discussion

In this comprehensive, population-based study among adolescents we found a significant association between mental distress and AD as well as for some other chronic diseases or complaints. Except for rhinitis and allergy there was girl preponderance in reported prevalence for all other diseases and complaints. The association between headache and neck or shoulder pain and mental distress was significant in both sexes. However, having AD was significantly associated to mental distress for both sexes, but significantly stronger among boys.

A major strength of this study was that the entire population of adolescents 13-19 years of age was included, with a very high response rate. Any major selection bias problems due to nonresponders are therefore unlikely.

The questions used to assess AD were questions from ISAAC. The extensive use of ISAAC questions on AD and asthma ensures comparison with other studies. ISAAC comprises a set of disease symptoms and was developed to provide standardized tools for studying the worldwide prevalence of atopic diseases in children. In this study, we have chosen to combine the questions on symptoms in order to define AD. The typical localization of the itchy rash, together with its duration in time, make the possibility of including other skin diseases less likely.

SCL-5 is a short version of the SCL-25, which again originates from the Hopkins SCL-90. SCL-25 is widely used in population-based surveys. It has been shown to be of satisfactory validity and reliability as a measure of psychological distress¹⁸²⁰ and it is recommended for screening of psychiatric disorders in epidemiological surveys.^21,22 The short version, SCL-5, has also been validated.¹⁶ In the validation survey, persons over 15 years were included. It is uncertain, therefore, how well the SCL-5 also assesses mental distress in the youngest age groups. However, as the youngest group consisted of persons aged 13-16, and the short version is validated for those 15 years and older, the age gap is modest.

The definition of a healthy control group is disputable, as the healthy group might include some adolescents with other chronic and serious diseases not explored in this survey. However, most adolescents are healthy in this regard²³ and the number of severely ill students in this age group amounts to an insignificant number.

Concerning mental health in adolescents with chronic diseases or complaints, reports have been controversial.^13,24,25 One of the problems with generalizing from these findings is that a great variety of different chronic diseases are explored.

Results from a Norwegian study of subjective health complaints in adolescence showed that most symptoms increased with age.²⁶ The most frequently reported symptoms were headache, backache and musculoskeletal complaints. Girls reported significantly more symptoms than boys. One of three 15-year-old girls as opposed to one of every fifth boy the same age reported at least one psychological or somatic complaint daily. The sex differences increased with age, which are consistent with other studies.^27,28 Sex differences in reporting diseases and complaints well known among adults^29,30 were also observed among young adults, and increased with age. Except for asthma, in the Young-HUNT study the association between AD, rhinitis, headache, neck or shoulder pain and mental distress increased with age for both sexes.

In a Spanish study, chronic illnesses were found to be associated with substantive emotional distress and suicide ideation in females but not in males.¹³ The chronic diseases included asthma, diabetes, seizures and cancer.

In a Norwegian prospective survey among 510 boys and 414 girls, 13-16 years without any known chronic diseases, girls reported being more depressed than boys.³¹ Strand et al.¹⁶ found that females 16-24 years old reported more mental distress than those 25-74 years old. Among the men, this trend was also present, but not significant. This corresponds well with the Young-HUNT population, in which girls reported more symptoms of mental distress than the boys.

In the Young-HUNT study, girls reported subjective health problems more often than boys.³² For this particular age group, expressing health problems might be more acceptable for girls than boys in the western culture.³¹ Puberty and maturity may also affect reporting of symptoms. Girls in this age group might also be more self-conscious than boys of the same age due to an earlier onset of puberty. We have accounted for the age differences in the multivariate analysis (Table 5). Despite the discrepancies in emotional development of adolescent boys compared with girls, we found a difference in reporting mental distress among boys 13-16 years old compared with girls 13-16 years old that cannot be accounted for by age alone.

The association between AD and reduced mental health as well as a decrement in HRQL is already well established in both children and adult populations.^911,32 As opposed to some other chronic complaints or diseases, little has been known about the consequences of AD on mental health among adolescents. Intuitively, young people facing skin problems in their teenage years would be expected to have an additional burden affecting mental distress, and even more so than those with invisible illnesses. Adolescence is a fragile period in life where there are great concerns on being healthy and good looking. Due to this, it is not surprising that any chronic disease, AD included, has an impact on adolescent wellbeing and state of mind as shown in this study. Having AD is also considered having a chronic disease, with many implications for the wellbeing of those affected. What was surprising was that the implications of having skin problems such as AD seemed to be a greater burden, as noted in reporting more mental distress, for boys than for girls.

Conclusion

Self-reported mental distress among adolescents with AD differed regarding sex and age. AD and mental distress as well as most other chronic complaints were reported more prevalently among girls. Both girls and boys aged 17-19 years reported more symptoms than those aged 13-16 years. There was a strong and consistent association between mental distress and AD, headache and neck or shoulder pain for both sexes. However, for adolescents with AD, the association between symptoms and mental distress was stronger for boys than for girls.

Acknowledgments

The Youth part of the Nord-Trondelag Health Study (the Young-HUNT study) is a collaboration between HUNT Research Centre, Faculty of Medicine, Norwegian University of Science and Technology (NTNU, Verdal), Norwegian Institute of Public Health and Nord-Trondelag County Council.

References