Psychiatric comorbidity in individuals with bullous pemphigoid and all bullous disorders in the Danish national register
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RESEARCH ARTICLE
Open Access
Psychiatric comorbidity in individuals with bullous pemphigoid and all bullous disorders in the Danish national registers Marianna Rania1,2,3, Liselotte Vogdrup Petersen4,5, Michael Erikson Benros6, Zhi Liu7, Luis Diaz7 and Cynthia M. Bulik3,8,9*
Abstract Background: Bullous pemphigoid (BP) is an autoimmune blistering skin disease that takes a profound physical and mental toll on those affected. The aim of the study was to investigate the bidirectional association between BP and all bullous disorders (ABD) with a broad array of psychiatric disorders, exploring the influence of prescribed medications. Methods: This nationwide, register-based cohort study encompassed 6,470,450 individuals born in Denmark and alive from 1994 to 2016. The hazard ratios (HRs) of a subsequent psychiatric disorder in patients with BP/ABD and the reverse exposure and outcome were evaluated. Results: Several psychiatric disorders were associated with increased risk of subsequent BP (4.18-fold for intellectual disorders, 2.32-fold for substance use disorders, 2.01-fold for schizophrenia and personality disorders, 1.92–1.85-1.49-fold increased risk for organic disorders, neurotic and mood disorders), independent of psychiatric medications. The association between BP and subsequent psychiatric disorders was not significant after adjusting for BP medications, except for organic disorders (HR 1.27, CI 1.04–1.54). Similar results emerged with ABD. Conclusion: Psychiatric disorders increase the risk of a subsequent diagnosis of BP/ABD independent of medications, whereas medications used for the treatment of BP/ABD appear to account for the subsequent onset of psychiatric disorders. Clinically, an integrated approach attending to both dermatological and psychiatric symptoms is recommended, and dermatologists should remain vigilant for early symptoms of psychiatric disorders to decrease mental health comorbidity. Keywords: Bullous pemphigoid, Bullous disorders, Mental health, Psychiatric disorders, Comorbidity
Background Bullous pemphigoid (BP) is categorized among a heterogeneous panel of bullous disorders (ABD), and is characterized clinically by itchy and tense serous or hemorrhagic sub-epidermal blisters that can be localized
* Correspondence: [email protected] 3 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden 8 Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Full list of author information is available at the end of the article
or widespread on the trunk and extremities and typically affects older individuals [1, 2]. The incidence of BP in Europe is estimated to be 2.5– 42.8 cases/million/year [3–9], with incidence increasing over the past eight decades [10] and a nearly 300-fold increase in those over age 90 compared to those younger than 60 [4]. This rise may reflect increasing average life expectancy, increasing use of polypharmacy, and improved detection and diagnosis [5]. BP is associated with considerable f
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