Table 4.

Psychiatric co-morbidity related evidence for Cumulative Life Course Impairment

Reference	Study type	Patients	Assessment tool	Evidence
Psychiatric
Singam et al. (2019)[54]	Retrospective cross-sectional study	87,053,155 adults and children with AA Reference group included all patients without AA	20% sample of US hospitalizations (2002-2012)	Inpatients with versus without AA had higher proportions of any and primary mental health diagnosis (P<0.0001) The mean length and cost of primary hospitalization for a mental health disorder in patients with AA were 6.0 days and $11,907Patients with AA were at an elevated risk of suicide and intentional self-inflicted injury (adjusted OR: 2.77, 95% CI: 1.66-4.63)
Chu et al. (2012)[55]	Case-controlled study	5117 outpatients diagnosed with AA by dermatologist	Data from the National Health Insurance Database of Taiwan	An increased risk of depression (OR: 2.23; CI: 1.09-4.54) was found in patients with AA aged<20 years An increased rate of anxiety (OR: 1.43; CI: 1.15-1.77) was observed with AA onset between ages of 20-39 yearsThe highest odds of OCD (OR: 3.00; CI: 1.11-8.12) and anxiety (OR: 2.05; CI: 1.56-2.68) were observed in patients with AA aged 40-59 years
Dehghani et al. (2017)[56]	Cross-sectional survey study	30 patients with mild-moderate AA 30 patients with psoriasis, 30 vitiligo, 30 acne, 30 controls	Toronto Alexithymia Scale-20	50% of AA patients were found to be alexithymic, as compared to 37% for vitiligo and 40% for psoriasis
Sellami et al. (2014)[57]	Case-controlled study	50 patients with new-onset AA 50 healthy controls	Hospital Anxiety and Depression ScaleToronto Alexithymia Scale-20Severity of Alopecia Tool	Rates of depression (P=0.047) and anxiety (P=0.005) were increased in AA patients as compared by controls
Lee et al. (2019)[58]	Nationwide population-based cohort study	Patients with at least 3 documented visits with ICD-10 code for AA Control patients 18+years and alive at the end of 2006	Cause of death and mortalities	Mortality risk associated with intentional self-harm/psychiatric diseases was significantly increased in AA patients Young adult patients and those with AT/AU had approximately 2-fold higher riskPatients with AA had higher mortality from smoking-associated cancers (lung and pancreatic)
Hwang et al. (2019)[59]	Longitudinal cohort study	4707 patients with newly onset AA370,019 controls	Number of visits to psychiatric clinic	The ratio of patients visiting a psychiatric clinic was approximately 1.6 × higher in AA patients than controlsAdjusted hazard ratios for psychiatric visits were significantly increased according to the number of intralesional injection treatments
Karia et al. (2015)[60]	Case-control study	50 patients with AA 50 with psoriasis 50 controls	Clinical interviewingSeverity of Alopecia ToolWHO-QoL ScaleHamilton rating scale for anxiety and depression	22% of AA patients suffered from psychiatric disorder, depression present in 18%, anxiety present in 4%. Control group had only 6% of psychiatric comorbidities
Bilgiç et al. (2014)[61]	Case-control study	74 children with AA65 matched controls	Severity of Alopecia ToolChild Depression Inventory State-Trait Anxiety Inventories for Children Pediatric QoL Inventory	For children ages 8-12: mean-state anxiety (P=0.003) and trait-anxiety (P=0.004) scores were significantly higher, parent-rated psychosocial QoL (P=0.001) and HRQL (P=0.009) were significantly lower than for controls
Baghestani et al. (2015)[62]	Case-control study	68 AA patients68 controls	Hamilton rating scale for anxiety and depression	The means of anxiety scores in cases and control group were 12.76±7.21 versus 8.54±6.37, P=0.003. Similarly, the means of depression scores for the groups were 12.84±4.03 versus 6.22±4.95, P=0.001

HRQL – Health-related quality of life; CI – Confidence interval; OR – Odds ratio; QOL – Quality of life; AA – Alopecia areata; ICD – International classification disease; AT - Alopecia totalis; AU - Alopecia universalis