|Year : 2022 | Volume
| Issue : 2 | Page : 127-130
Association between vitiligo and risk of suicide and suicidal ideation: systematic review and meta-analysis
Kevin Phan1, Stephen Shumack2, Monisha Gupta3
1 Department of Dermatology, Liverpool Hospital, Sydney; Faculty of Medicine, University of New South Wales, Sydney; St George Dermatology and Skin Cancer Centre, Kogarah, Sydney, Australia
2 St George Dermatology and Skin Cancer Centre, Kogarah, Sydney, Australia
3 Department of Dermatology, Liverpool Hospital, Sydney; Faculty of Medicine, University of New South Wales, Sydney, Australia
|Date of Submission||30-Sep-2020|
|Date of Decision||25-May-2021|
|Date of Acceptance||12-Jun-2021|
|Date of Web Publication||12-Aug-2022|
Dr. Kevin Phan
Department of Dermatology, Liverpool Hospital, Sydney
Source of Support: None, Conflict of Interest: None
Background: Vitiligo is an autoimmune skin disorder characterized by patches of depigmentation due to loss of melanocytes. Vitiligo is associated with significant psychosocial burden, with prior studies showing links with psychiatric comorbidities such as depression. Few studies have evaluated the relationship between vitiligo and suicidal ideation and suicide attempts. We aimed to investigate the underlying prevalence and risk of suicidal ideation or suicide attempts among patients with vitiligo. Materials and Methods: A systematic search of PubMed, MEDLINE, Embase, and the Cochrane Library was conducted. Cross‐sectional, case–control or cohort studies that assessed the prevalence of suicidal ideation or suicide attempts among patients with vitiligo were included. DerSimonian and Laird random‐effects models were utilized to calculate the pooled prevalence and odds ratios. Results: From systematic review, we identified seven studies included for analysis. A total of 12,043 vitiligo cases were compared with 87,053,333 controls. The pooled proportion of suicidal ideation in vitiligo was 15.2% compared to 2.0% in the control group (P < 0.001). The proportion of suicide attempts/suicides was also higher for vitiligo compared to controls (3.2% vs. 2.1%, P < 0.001). Moderate‐to‐high heterogeneity was observed between the studies. Conclusion: Our data further provide evidence of the significant impact vitiligo has on self-esteem and psychological burden. Patients with vitiligo were significantly more likely to have suicidal ideation. Clinicians should actively evaluate patients with vitiligo for signs/symptoms of suicidal ideation and provide appropriate referrals to manage their psychiatric symptoms accordingly.
Keywords: psychiatric disorder, suicide, vitiligo
|How to cite this article:|
Phan K, Shumack S, Gupta M. Association between vitiligo and risk of suicide and suicidal ideation: systematic review and meta-analysis. Pigment Int 2022;9:127-30
| Introduction|| |
Vitiligo is an autoimmune skin disorder characterized by patches of depigmentation due to loss of melanocytes. It often affects visible sites and has a chronic course with no reliable satisfactory treatment. Vitiligo is commonly associated with significant psychosocial burden, with studies showing links with psychiatric comorbidities such as depression. Vitiligo also has a negative impact on patient quality of life, affecting self-confidence, and their participation in school, work, and relationships. These patients often endure significant distress and negative social stigma. Vitiligo has been triggered by antecedent psychological factors, hence psychological factors can cause the disease and the disease itself can further result in psychological distress. Despite vitiligo accounting for over $10 million cost for hospitalization for mental health comorbidities in the United States, there is limited available evidence evaluating the relationship between vitiligo and mental health emergencies such as suicidal ideation and suicide attempts.
| Materials and methods|| |
We aimed to investigate the underlying prevalence and risk of suicidal ideation or suicide attempts among patients with vitiligo. A systematic search of PubMed, MEDLINE, Embase, and the Cochrane Library was conducted according to PRISMA guidelines. Searches were performed in these databases from their dates of inception to December 2020. To achieve maximum sensitivity of the search strategy and identify all studies, we combined the terms: “vitiligo,” “pigmentary disorder,” “hypopigmentation,” “suicide,” “suicidal ideation,” “self-harm,” “psychological,” and “psychiatric,” as either keywords or MeSH terms. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant studies. All identified articles were systematically assessed using the inclusion and exclusion criteria.
Cross‐sectional, case–control, or cohort studies that assessed the prevalence of suicidal ideation or suicide attempts among patients with vitiligo were included. All studies must have included either the proportion of patients with suicide or suicidal ideation in each group, or the summary effect size for association between vitiligo and suicide or suicidal ideation. When institutions published duplicate studies with accumulating numbers of patients or increased lengths of follow-up, only the most complete reports were included for quantitative assessment at each time interval. All publications were limited to those involving human subjects. Language was not an exclusion factor. Case reports, conference presentations, editorials, and expert opinions were excluded. Review articles were omitted because of potential publication bias and duplication of results.
Data were extracted from article texts, tables, and figures. Data collected included study characteristics, proportion of patients with suicide, or suicidal ideation in the vitiligo cohort versus nonvitiligo control cohort. If the proportion data were not available, then effect size either in the form of odds ratio, relative risk, or hazard ratio with 95% confidence interval (CI) was collected.
A meta-analysis of proportions was conducted. Firstly, to establish variance of raw proportions, a logit transformation was applied. Secondly, to incorporate heterogeneity (anticipated among the included studies), transformed proportions were combined using DerSimonian–Laird random-effects models. Finally, the pooled estimates were back transformed. Heterogeneity was evaluated using Cochran Q and I2 test. Pooled proportions are presented with 95% CIs. To determine whether proportion of suicides and suicidal ideation was different between vitiligo versus control cases, meta-regression was conducted. P-values <0.05 were considered significant. All analyses were performed using the metafor package for R version 3.02 (R Foundation for Statistical Computing, Vienna, Austria).
| Results|| |
From systematic review, we identified seven studies included for analysis,,,,,, [Figure 1]. A total of 12,043 vitiligo cases were compared with 87,053,333 controls [Table 1].
|Figure 1 PRISMA flow chart demonstrating the search strategy for the present systematic review and meta-analysis.|
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|Table 1 Characteristics of included studies in the present systematic review and meta-analysis|
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The pooled proportion of suicidal ideation in vitiligo was 15.2% (95% CI 9.3–23.7%) compared to 2.0% (95% CI 0.7–5.1%) in the control group (P < 0.001) [Figure 2]. The proportion of suicide attempts/suicides was also higher for vitiligo (3.2%; 95% CI 1.2–8.3%) compared to controls (2.1%; 95% CI 0.6–7.5%) (P < 0.001), although the absolute difference was smaller. Moderate‐to‐high heterogeneity was observed between the studies.
|Figure 2 Forest plot showing meta-analysis of pooled proportion of suicidal ideation in vitiligo cases versus control group.|
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| Discussion|| |
Vitiligo is a chronic disease characterized by partial or complete destruction of melanocytes in affected skin, resulting in hypopigmented macules. Although vitiligo is not a contagious condition, given the physical appearance, it can have a considerable impact on quality of life of patients. This may be due to stress related to the physical appearance of vitiligo, low self-esteem and confidence, embarrassment, negative social stigma, affected sexual relations, social isolation, and vitiligo-related discrimination. Loss of confidence can limit further attempts at socializing which further compounds their reduced sense of self-worth, worsens psychological distress, which may lead to suicidal ideation and ultimately suicide attempts, and suicide.,
Although there are several studies which investigate the association of vitiligo with anxiety and depression, there is limited pooled evidence on the issue of suicidal ideation and suicides in this population. Our meta-analysis demonstrates a significant association between vitiligo with suicidal ideation but not suicide cases. Our data provide evidence of the underestimated significant impact vitiligo has on self-esteem and psychological burden, particularly with the significant association with suicidal ideation. Our study supports evidence of strong associations between vitiligo and multiple mental health comorbidities including anxiety, depression, suicidal risk, personality disorder, and alcohol-related disorders. Furthermore, an Indian study showed that patients with vitiligo with suicidal ideation were more likely to use alcohol as a coping mechanism.
Prior studies have suggested that female vitiligo cases have higher rates of levels of hopelessness and anxiety compared with male cases. Hamidizadeh et al. conducted a comparative study of 100 patients with vitiligo with 100 healthy controls, and found that female vitiligo cases were significantly associated with severe depression and severe anxiety. In our meta-analysis, due to limited reporting by the included studies, we were not able to assess whether the association between vitiligo and suicidal ideation differs between females in comparison to males, and this remains subject to further investigation.
Our current findings have several limitations. Firstly, it is a meta-analysis of lower quality studies. Most included studies were prevalence or cross-sectional studies. The assessment or determination of suicidal ideation varied significantly among included studies, but included the quick inventory of depressive symptomatology (16-Item) (Self-Report) (QIDS-SR-16), ICD-9CM, HAMD, HRDS, Beck Depression, Hindi general health questionnaire (GHQ) questionnaires, as well as author’s own questionnaire. There is also heterogeneity in terms of controls used, which included patient relatives as well as nonvitiligo dermatological patients seen in the same clinic. As such, this introduces considerable heterogeneity and limits interpretation of pooled results. There is also a lack of data on severity of vitiligo, distribution, and previous or ongoing treatments which may influence findings. Patients were predominantly of Indian or Middle Eastern background, and thus whether these findings can be applicable broadly requires further studies as vitiligo in people of color is more noticeable and carries a higher social stigma due to cultural reasons. There is also the potential for cases of suicide or suicidal ideation to be underreported, given that the majority of included studies are retrospective in nature.
There are significant clinical implications from the results of this study. Our study supports the notion that vitiligo is a cosmetically distressing disorder and has considerable mental health comorbidities including suicidal ideation. Treating physicians should explore the impact on the quality of life, including mental health issues, and provide appropriate referrals to manage these issues to ensure holistic treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Silverberg JI, Silverberg NB. Association between vitiligo extent and distribution and quality-of-life impairment. JAMA Dermatol 2013;149:159-64.
Kent G, Al’Abadie M. Psychologic effects of vitiligo: a critical incident analysis. J Am Acad Dermatol 1996;35:895-8.
Silverberg JI, Silverberg NB. Vitiligo disease triggers: psychological stressors preceding the onset of disease. Cutis 2015;95:255-62.
Patel KR, Singam V, Rastogi S, Lee HH, Silverberg NB, Silverberg JI. Association of vitiligo with hospitalization for mental health disorders in US adults. J Eur Acad Dermatol Venereol 2019;33:191-7.
Kota RS, Vora RV, Varma JR, Kota SK, Patel TM, Ganjiwale J. Study on assessment of quality of life and depression in patients of vitiligo. Indian Dermatol Online J 2019;10:153.
] [Full text]
Sangma LN, Nath J, Bhagabati D. Quality of life and psychological morbidity in vitiligo patients: a study in a teaching hospital from North-East India. Indian Dermatol Online J 2015;60:142.
Ramakrishna P, Rajni T. Psychiatric morbidity and quality of life in vitiligo patients. Indian J Psychol Med 2014;36:302.
] [Full text]
Pahwa P, Mehta M, Khaitan BK, Sharma VK, Ramam M. The psychosocial impact of vitiligo in Indian patients. Indian J Dermatol Venereol Leprol 2013;79:679-85.
] [Full text]
Layegh P, Arshadi HR, Shahriari S, Nahidi Y. A comparative study on the prevalence of depression and suicidal ideation in dermatology patients suffering from psoriasis, acne, alopecia areata and vitiligo. Ir J Dermatol 2010;4:106-11.
Sharma N, Koranne RV, Singh RK. Psychiatric morbidity in psoriasis and vitiligo: a comparative study. J Dermatol 2001;28:419-23.
Hamidizadeh N, Ranjbar S, Ghanizadeh A et al.
Evaluating prevalence of depression, anxiety and hopelessness in patients with vitiligo on an Iranian population. Health Qual Life Outcomes 2020;18:20.
[Figure 1], [Figure 2]