Acne is a common disease in adolescence with female preponderance. It could cause poor self-esteem and social phobia. Previous studies based on questionnaires from several thousands of adolescents showed that acne is associated with major depression and suicide. However, the gender- and age-specific risk of depression and suicide in patients with acne remain largely unknown. Using a database from the National Health Insurance, which included 98% of the population of Taiwan in 2006, we identified patients of acne, major depression, and suicide based on ICD-9-CM codes. Totally 47111 patients with acne were identified (16568 males and 30543 females) from 1 million subjects. The youths of 7–12 years had the highest prevalence of acne (14.39%). Major depression was more common in those with acne (0.77%) than controls (0.56% ,
Acne is a common skin disease in adolescence and can persist, in some cases, into adulthood [
Major depression is recognized as a persistent low mood accompanied by low self-esteem, feelings of worthlessness, and a loss of general interest. Suicide attempt is an indicator of emotional distress and tends to occur in patients with major depression. Major depression is a well-known major risk factor of suicide [
As compared to men, in general, women have a higher chance of developing major depression, anxiety, and neurotic disorder and might have overall impaired quality of life [
Acne tends to affect females with a male to female ratio about 1/1.1–1.25 in Asians [
In this study, we aimed to determinate the age- and gender-specific prevalence of acne in Taiwan. In addition, we also evaluated the associations between acne and depressions and suicides. We also estimated the impact of female gender and acne disease on the risk of major depression and suicide.
This is a population-based study using the claim data collected by the National Health Insurance (NHI). Taiwan NHI is a program of health-care system. In 2006, more than 98% of Taiwan’s population (about 23 million) was enrolled in this program. Therefore, our study population consists of almost the whole population of Taiwan in 2006. Based on the NHI database of year 2006, we collected and analyzed data related to acne, major depression, and suicide attempt as defined by the International Classifications of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Ascertainment of acne involves the selection of ICD-9-CM codes for acne including 706.1 with other acne, 706.2 with sebaceous cyst, 706.3 with seborrhea, 706.8 with other specified diseases of sebaceous glands, and 706.9 with unspecified disease of sebaceous glands. Further, we chose ICD-9-CM codes for major depression, including 296.2 with major depressive disorder single episode and 296.3 with major depressive disorder recurrent episode. ICD-9-CM codes for suicide attempt include the following: E950 with suicide and self-inflicted poisoning by solid or liquid substances, E951 with suicide and self-inflicted poisoning by gases in domestic use, E952 with suicide and self-inflicted poisoning by other gases and vapors, E953 with suicide and self-inflicted injury by hanging strangulation and suffocation, E954 with suicide and self-inflicted injury by submersion (drowning), E955 with suicide and self-inflicted injury by firearms air guns and explosives, E956 with suicide and self-inflicted injury by cutting and piercing instrument, E957 with suicide and self-inflicted injuries by jumping from high place, E958 with suicide and self-inflicted injury by other and unspecified means, and E959 with late effects of self-inflicted injury.
The prevalence of acne and depression was stratified by sex and age group. The 95% CI of the prevalence was estimated by the Poisson distribution model. In the univariate analysis, the association between acne and the prevalence of major depression and suicide was tested using Fisher’s exact test for categorical variables. The relationship between acne and prevalence of the major depression was assessed by logistic regression. Results are presented as odds ratios (OR) and 95% confidence intervals (95% CI). Interactions between acne and gender were tested under multiple logistic regression models using an added interaction term (acne × gender) and main covariates, age categories. A
To investigate the general prevalence rate of acne in Taiwan, we used the Taiwan National Health Insurance (NHI) database with a random sampling of one million patients visiting health care providers in 2006 to estimate the overall prevalence of acne (Table
Prevalence of acne in Taiwan, 2006.
ICD-9-CM 706.x | At risk population | Prevalence (95% CI) | |
---|---|---|---|
|
| ||
Men | |||
Overall | 16568 | 495838 | 3.34% (3.29%–3.39%) |
Age category, years | |||
0–6 | 4234 | 110114 | 3.85% (3.73%–3.96%) |
7–12 | 4291 | 39800 | 10.78% (10.48%–11.09%) |
13–18 | 2732 | 46295 | 5.90% (5.69%–6.12%) |
19–24 | 1482 | 48014 | 3.09% (2.94%–3.25%) |
25–30 | 956 | 51107 | 1.87% (1.76%–1.99%) |
31–42 | 1355 | 96541 | 1.40% (1.33%–1.48%) |
>42 | 1518 | 103967 | 1.46% (1.39%–1.54%) |
Women | |||
Overall | 30543 | 504162 | 6.06% (5.99%–6.12%) |
Age category, years | |||
0–6 | 4711 | 100662 | 4.68% (4.55%–4.81%) |
7–12 | 7549 | 42469 | 17.78% (17.42%–18.14%) |
13–18 | 7098 | 50167 | 14.15% (13.85%–14.46%) |
19–24 | 4184 | 51782 | 8.08% (7.85%–8.32%) |
25–30 | 2957 | 54410 | 5.44% (5.25%–5.63%) |
31–42 | 2859 | 98842 | 2.89% (2.79%–3.00%) |
>42 | 1185 | 105830 | 1.12% (1.06%–1.19%) |
Combined group | |||
Overall | 47111 | 1000000 | 4.71% (4.67%–4.75%) |
Age category, years | |||
0–6 | 8945 | 210776 | 4.24% (4.16%–4.33%) |
7–12 | 11840 | 82269 | 14.39% (14.15%–14.63%) |
13–18 | 9830 | 96462 | 10.19% (10.00%–10.38%) |
19–24 | 5666 | 99796 | 5.68% (5.54%–5.82%) |
25–30 | 3913 | 105517 | 3.71% (3.60%–3.82%) |
31–42 | 4214 | 195383 | 2.16% (2.09%–2.22%) |
>42 | 2703 | 209797 | 1.29% (1.24%–1.34%) |
To further define the impact of gender in the development of major depression and suicide attempt in patients with acne, we first performed the association analysis of acne and major depression/suicide as stratified by the gender. The overall prevalence of major depression and suicide attempts in patients with acne was 0.77% and 0.01%, respectively (Table
Patients with acne tend to develop major depression and commit suicide in both genders.
ICD-9-CM 706.x | Non-ICD-9-CM 706.x |
| |
---|---|---|---|
|
| ||
|
|||
Major depression (296.2 + 296.3) | |||
+ | 101 (0.61) | 1851 (0.39) | <0.0001 |
− | 16467 (99.39) | 477419 (99.61) | |
Suicide ( |
|||
+ | 1 (0.01) | 23 (0.00) | 0.5577 |
− | 16567 (99.99) | 479247 (100.00) | |
|
|||
Major depression (296.2 + 296.3) | |||
+ | 261 (0.85) | 3453 (0.73) | 0.0142 |
− | 30282 (99.15) | 470166 (99.27) | |
Suicide ( |
|||
+ | 6 (0.02) | 45 (0.01) | 0.1281 |
− | 30537 (99.98) | 473574 (99.99) | |
|
|||
Major depression (296.2 + 296.3) | |||
+ | 362 (0.77) | 5304 (0.56) | <0.0001 |
− | 46749 (99.23) | 947585 (99.44) | |
Suicide ( |
|||
+ | 7 (0.01) | 68 (0.01) | 0.0900 |
− | 47104 (99.99) | 952821 (99.99) |
We have shown that patients with acne and females are both associated with an increased risk of major depression and suicide (Table
Acne and gender, independently and jointly, associated with the risk of major depression.
Major depression | Nonmajor depression | Adjusted OR (95% CI)* |
|
|
---|---|---|---|---|
Acne (no) and men | 1851 (32.67) | 477419 (48.01) | 1.00 | |
Acne (no) and women | 3453 (60.94) | 470166 (47.28) | 1.85 (1.75–1.96) | |
Acne (yes) and men | 101 (1.78) | 16467 (1.66) | 2.12 (1.73–2.60) | |
Acne (yes) and women | 261 (4.61) | 30282 (3.05) | 2.78 (2.43–3.17) | −0.35, 0.0043 |
Similarly, our results showed that both acne and women are associated with the risk of suicide (Table
Acne and gender, independently and jointly, associated with the risk of suicide.
Suicide | Nonsuicide | Adjusted OR (95% CI)* |
|
|
---|---|---|---|---|
Acne (no) and men | 23 (30.67) | 479247 (47.93) | 1.00 | |
Acne (no) and women | 45 (60.0) | 473574 (47.36) | 1.96 (1.18–3.23) | |
Acne (yes) and men | 1 (1.33) | 16567 (1.66) | 1.10 (0.15–8.24) | |
Acne (yes) and women | 6 (8.00) | 30537 (3.05) | 3.17 (1.27–7.94) | 0.39, 0.7280 |
This study analyzed data from a large random sample of the general population in Taiwan. Acne was commonly thought to be only a skin problem that usually affected the adolescence. This study indicated the 7–12-year-old children being affected at the higher rates than adolescents (13–18 years old) and many adults also experience acne. In addition, females were more vulnerable to acne than males in all age groups. Consistent with our previous community-based study conducted by dermatologist’s direct inspection and diagnosis [
Clearance of acne was generally expected to occur spontaneously in early adulthood. However, acne remains a common skin disease after the second decade [
We found that major depression was more prevalent by 2-fold in patients with acne (0.77%) than general population in Taiwan (0.35%) [
The significance of the association of acne and major depression was higher in males and there was 2.12-fold increased risk of developing major depression in males with acne than those without. This claim data did not include disease severity as an outcome. Since the disease severity of acne is associated with social impairment [
Regarding the association of suicide and acne, an increased risk of suicide attempts in young people presenting with acne has been reported [
Isotretinoin is an effective therapeutic option for severe and recalcitrant acne. Use of isotretinoin was reported to be associated with depression and suicide attempts in patients with acne [
Our study highlighted that acne is an early onset and chronic skin disease which may influence mental health throughout lifetime, especially in females. Acne could not be considered simply as a superficial problem in physical appearances. The requirement of active screen for the comorbidities of psychological diseases, such as major depression and suicide, among the acne patients should be warranted.
Although the numbers of patients with acne identified are tens of thousands, there are some intrinsic limitations using the NHI database. Firstly, the doctors may not give an accurate ICD-9-CM codes upon visit. Patients with different ages, genders, and diseases may have different thresholds to visit doctors. Nonetheless, in this study, we still observed consistent female to male ratios and prevalence in patients with acne as compared to our previous studies, suggesting that the analysis based on NHI database may reflect at large the de facto situation. Secondly, the NHI database and the insurance forms could not address whether the females seek medical help earlier or the females were affected by the acne earlier. However, our previous community-based study indicated that comedones were actually identified in girls at age 6, which was 1 year earlier than that in boys. Thirdly, we could not distinguish reactive or endogenous depressions using this database. Further hospital-based case control study focusing on the association of acne and reactive/endogenous depression is needed.
We concluded that female gender and acne disease are jointly and independently associated with the risk of major depression and suicide. The results may provide useful decision making information to the public health policy decision makers to estimate the need of appropriate health care for patients with acne in our community. Education and encouragement of the people with acne, women in particular, to seek an appropriate medical, mental, and social support not only improve the physical appearance and self-esteem but also decrease the associated social consequences and burdens.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Yi-Chien Yang and Hung-Pin Tu have equal contributions, and Hung-Yi Chuang and Chih-Hung Lee have equal contributions.
This study was supported by Grants from the Taiwan National Science Council (99-2314-B-037-007-MY3, 100-2314-B-182A-096-MY3) and Chang Gung Medical Research Program (CMRPG8C0821) and is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health, and managed by the National Health Research Institutes. The interpretation and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or the National Health Research Institutes.