Discussion
We demonstrated significant differences in sleep and mental health measures between adults with AD and healthy controls. Using validated questionnaires, the AD group reported poorer sleep quality and more severe insomnia symptoms than the control participants. Our results align with recent studies that showed lower sleep quality, higher sleep disturbances, and a greater risk of insomnia in adult AD patients5,38.
AD patients also presented more severe depressive symptoms than controls. On the other hand, we did not observe a significant difference in anxiety between the two groups. The current literature on the mental health of the AD population seems consistent in showing high rates of depression and anxiety in adults with AD compared to the general population18,39. However, previous studies have found conflicting results regarding whether AD is associated with increased mental health disorders15.
Our results also showed higher levels of perceived stress in the AD group compared with controls. Psychological stress has been identified as a major aggravating factor in AD22. Similarly, itching, discomfort, disfigurement, perceived social stigmatization, isolation, poor quality of life, and sleep disturbances lead the AD population to experience more psychological distress2,40–42. However, comparative studies between AD and healthy adults have not been reported.
The present study also showed that objective and subjective severity of AD significantly predicted sleep quality and insomnia. More severe AD was associated with worse sleep quality and greater insomnia symptoms. Several recent studies also reported that sleep disturbances seem to worsen with the severity of AD8,9,23,43. Moreover, our results highlighted that, although objective and subjective disease severity similarly predict sleep quality, patient-oriented subjective severity of AD appeared to contribute more to the manifestation of insomnia symptoms in AD adults.
AD patients may experience a significant amount of itching, pain, and discomfort, which can lead to sleep disturbances6. Although objective measures of AD provide a quantitative assessment of the disorder, the subjective severity of AD may be a more complete and accurate predictor of insomnia, taking into account the physical and psychological factors of the condition.
To the same extent, objective and subjective severity of AD also predicted anxiety symptoms and self-perceived stress. On the other hand, the self-perceived severity of AD, but not the objective measure, significantly predicted depressive symptoms. Therefore, anxiety and stress symptoms of AD patients increased with increasing objective and subjective severity of the disease. However, depressive symptoms exhibited by AD adults were exclusively related to personal perception of disease severity.
A recent study highlighted higher levels of self-perceived stress in patients with severe AD 19, similar to our findings. Two recent meta-analyses showed a significant positive association between AD and anxiety and depression16,18. Silverberg et al.15 found that patients with moderate and severe AD had significantly worse mental health than those with mild AD. The relation between the clinical severity of AD and psychological well-being is central to clinician behaviour. When treating patients with moderate-to-severe AD, dermatologists should be vigilant and screen and refer to a specialist for psychiatric symptoms.
Recently, the absence of a causal role of AD in the development of depressive and anxiety disorders has been proposed44, supporting the existence of an indirect link between AD and psychological measures driven by other concomitant conditions. In this regard, recent studies suggested that sleep disturbances might predispose AD patients to experience psychological symptoms45,46.
Although the present study aligns with the recent literature, our results suggest a different impact of objective and subjective AD severity on the global disease burden. In clinical practice, there is a wide discrepancy between patient-oriented subjective evaluation and clinician-oriented measurement47. This could be partially explained by physicians’ underestimation of the intensity of symptoms. Moreover, the severity of AD partially depends on the personal perception that individuals attribute to the disorder25. Our results underline the importance of using patient-oriented severity tools alongside objective indexes in clinical and research practice.
Overall, AD appears to strongly affect the physical and mental well-being of patients, with a considerable impact on sleep and psychological health. However, the pathogenesis of sleep and psychological disorders in AD patients is complex and not fully understood4,14. Currently, there is a need for a consensus guiding the evaluation and management of sleep and psychological disorders in AD patients. In detail, most dermatological investigations do not focus on evaluating sleep disorders, limiting the management and treatment of these disturbances. Polysomnography and actigraphy are objective and valid but impractical in dermatological studies5. However, the use of self-administered validated questionnaires could easily guarantee the evaluation of sleep quality in AD patients5, also offering the possibility to follow the time course of the disturbance. On the psychological side, there are no specific tools designed for the psychological assessment of AD patients in the clinical setting48. In addition to an overall analysis of the patient’s quality of life, physicians and researchers should also pay more attention to the specific psychological symptoms exhibited by AD patients, such as depression, anxiety, and psychological stress, which could exacerbate the severity of the skin condition, triggering a vicious circle from which it is challenging to get out16,18.
Our study has limitations. Our findings were obtained in a small clinical sample undergoing different pharmacological treatments. The assessment of insomnia, depression/anxiety symptoms, and stress using self-reported tools might have produced a selection bias by including only individuals able to complete questionnaires via a digital medium. However, in our study, the use of electronic questionnaires at home was well accepted by patients, reduced the risk of non-completion in waiting or dedicated rooms, and minimized the risk of incomplete filling or erroneous completion.
In conclusion, the present study showed poor sleep quality and high levels of insomnia, depression, and perceived stress in AD patients, highlighting a worse health context for individuals with greater disease severity. The disease burden in AD is multifaceted and difficult to estimate as in addition to the severity of the condition as represented by clinical signs, poorer sleep quality, severe insomnia conditions, the coexistence of underdiagnosed anxiety/depression symptoms, and impaired stress responses are disease-specific symptoms that contribute to the broad impact of the disease on patients’ life. Overall, our results suggest the importance of adopting a multidisciplinary approach to the management and treatment of patients with AD, ensuring an adequate screening for sleep and psychological disorders, with particular attention to personal perception of disease severity.