Hidradenitis Suppurativa Linked to Higher Risk of Self-Harm, Including Suicide

Patients with hidradenitis suppurative (HS) had a significantly higher incidence of self-harm, including suicide, compared with the general population, a large registry-based study from Denmark showed.

During follow-up for as long as 17 years, three times as many patients with HS had documented episodes of self-harm, which translated into a twofold higher hazard after adjustment for confounders, including participants in the control group with a history of self-harm. In a small number of patients who died by suicide, the risk was more than double in the patients with HS versus the control group.

Patients with HS had a higher prevalence of multiple adverse risk factors, reported Nikolaj Holgersen, MD, PhD, of Copenhagen University Hospital in Denmark, and colleagues in JAMA Dermatology.

“HS was associated with a higher hazard of self-harm overall, although this was attenuated by controls with prior self-harm episodes, who may have a psychiatric burden more equal to that of the HS population,” the authors stated. “HS was also associated with a higher hazard of suicide, with similar covariate profiles at death, suggesting HS as a potential contributing factor.

“Self-harm was more frequent before suicide in patients with HS versus controls, highlighting the importance of clinician awareness in a multidisciplinary setting.”

The study adds key information to existing evidence that HS is associated with increased risk of mental health disorders and suicide, said Steven Daveluy, MD, of Wayne State University in Detroit.

“HS can be an incredibly difficult disease that has an immense impact on quality of life,” Daveluy told MedPage Today. “When disease is not controlled, patients can’t forget they have HS, since it impacts just about everything in their life: clothing choices, activities, energy level, pain, and mood. That can be a huge burden on mental health, which is why it’s no surprise that depression, anxiety, and suicidality are comorbidities of HS.”

“In addition to the burden the disease puts on daily living, there is also evidence that uncontrolled inflammation can impact brain function and mood. This study highlights the importance of asking patients about their mental health,” he said. “[It] highlights the importance of asking about thoughts of self-harm, since self-harm behaviors were seen in many of the HS patients who died by suicide. This can serve as an important warning sign that could save a life.”

Even if a patient is not ready to talk about the mental or emotional toll of HS, asking the question “plants the seed and lets them know that you care about their mental health. I know that it can be uncomfortable to talk about mental health, but the more you do it, the easier it gets.”

Talking about the potential benefits of seeing a mental health specialist, including coping skills, can help normalize the discussion, he added.

Holgersen and colleagues reported findings from an analysis of 9,566 patients with HS in the National Danish Registries from Jan. 1, 2003 to Dec. 31, 2020. They were age- and sex-matched with 47,827 individuals from the general population. Using ICD-10 diagnostic codes, investigators identified episodes of self-harm and suicide and calculated incidence of self-harm per 1,000 person-years.

The two groups had a mean age of about 39, and women accounted for 69% of the total. Analysis of baseline characteristics showed that patients with HS had significantly higher rates of smoking (20.6% vs 5.9%) excessive alcohol use (8.8% vs 3.7%), drug use (8.8% vs 1.5%), mental health disorders (9.7% vs 4.0%) and prior episodes of self-harm (3.6% vs 1.4%).

During follow-up, 3.3% of patients in the HS group had an episode of self-harm versus 1.1% of the control group, which translated into incidence rates (IRs) of 4.26 versus 1.38 per 1,000 person-years. An adjusted model showed the HS group had a twofold higher risk (HR 2.13, 95% CI 1.81-2.51, P<0.001). The hazard versus the control group decreased to 1.43 for patients with a prior episode of self-harm (95% CI 1.02-2.02, P<0.05), increasing to 2.06 for patients with no prior episodes (95% CI 1.72-2.46, P<0.001).

In the HS group 17 patients died by suicide versus 31 in the control group, resulting in unadjusted IRs of 0.23 (95% CI 0.13-0.36) versus 0.08 (95% CI 0.05-0.11) per 1,000 person-years. After adjustment, the HS group had more than a twofold greater risk of suicide compared with the control group (HR 2.54, 95% CI 1.33-4.87, P=0.01).

Among the individuals who died by suicide, those in the HS group more often died by nonviolent methods (52.9% vs 29.0%) and had prior episodes of self-harm (41.7% vs 14.8%).