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Patients with alopecia areata (AA) had rates of anxiety and depression two to three times higher than the general population, and more than a third had suggestive symptoms, according to a meta-analysis of published data.

The results showed a 9% prevalence of depression and 13% prevalence of unspecified anxiety disorders. Additionally, 37% of the patients had depressive symptoms and 34% had anxiety symptoms. Variations in prevalence estimates could be explained by methodologic differences among the 55 studies included in the analysis.

Given the disparity between the prevalence of the disorders and symptoms, a multimodal approach to assessment in research might lead to improved detection of psychiatric disorders in patients with dermatologic conditions, concluded Isabelle Jalenques, MD, PhD, of CHU Clermont-Ferrand in France, and co-authors, in .

"This meta-analysis is, to our knowledge, the first to make separate assessments of depressive and anxiety disorders and symptoms in patients with AA," the researchers stated. "By distinguishing between disorders and symptoms, this analysis yielded more accurate data and also provided the prevalence of each anxiety disorder. This factor is important because prevalence varies according to the different disorders.

"However, given the small number of studies identified, caution should be exercised about their actual prevalence," the team continued. "Only phobia did not seem to be associated with AA."

The results are consistent with literature on the associations between dermatologic conditions and psychiatric disorders, but expand on the evidence by distinguishing between psychiatric disorders and symptoms. Two recent meta-analyses assessed associations in patients with AA. One analysis showed a positive association with anxiety and depression, and the other found a greater prevalence of anxiety and depression.

However, the two studies focused on the prevalence of anxiety and depression without distinguishing the disorders from symptoms, Jalenques and co-authors noted. Depending on the assessment methodology, inaccurate estimates can occur, particularly with respect to overestimate of psychiatric prevalence.

"The exact magnitude of the association between AA and depressive disorders or symptoms and anxiety disorders and symptoms is unknown," the authors said.

In an effort to bring more clarity to the estimates and associations, the investigators performed a systematic review and meta-analysis of relevant published studies. The team conducted separate analyses of the prevalence of the psychiatric disorders and prevalence of symptoms.

Beginning with 1,099 records, the authors honed the list to 55 studies that evaluated depression and anxiety in children and adults with AA -- 29 studies related to depression and 26 to anxiety. The studies represented 20,176 patients evaluated for depressive disorders, 1,966 for depressive symptoms, 40,877 patients for anxiety disorders (primarily phobias, unspecified disorders, and obsessive-compulsive disorder), and 1,621 for anxiety symptoms.

Using published literature, the authors identified prevalence estimates of 3.8% and 7.3% for and unspecified , respectively, in the general population. The 9% prevalence estimate for depressive disorders from the meta-analysis translated into an odds ratio of 1.38 versus the general population. The 13% estimate for anxiety disorders included a range of 7-17% for different types of disorders, resulting in odds ratios of 1.51-1.69.

The 37% prevalence of depressive symptoms in patients with AA represented an odds ratio of 2.70 versus the general population, and the 34% prevalence of anxiety symptoms represented a threefold increase (OR 3.07).

"It would be interesting to follow the evolution of the severity and number of these symptoms, which are warning signs that need monitoring because they can develop into disorders," the authors said in conclusion. "The substantial difference between the prevalence of disorders and that of symptoms is a strong argument in favor of using a multimodal assessment approach in research studies that could lead to a better detection of psychiatric disorders in patients with dermatological diseases."

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