Prevalence of Mental Health Symptoms in Chronic Urticaria: A Systematic Review and Meta‐Analysis

Chronic urticaria (CU) is an inflammatory skin condition lasting over 6 weeks characterized by recurring itchy wheals and/or angioedema [1]. CU affects 1%–2% of individuals worldwide [2] and has one of the greatest quality-of-life impairments among dermatologic conditions [3], with episodes of intense pruritus and wheals causing sleep disturbances and restricting patients' social lives [1]. Consequently, patients with CU experience greater rates of psychological comorbidities, including depression and anxiety, compared to the general population [4]. Despite CU patients' higher risk of mental health disorders, the relationship between CU and mental health symptoms is underrecognized, exacerbating the patients' unmet needs [5, 6]. This systematic review and meta-analysis estimates the prevalence of depressive symptoms, anxiety symptoms, and sleep disturbances in patients with CU. This review was registered on PROSPERO (c). We searched MEDLINE, Embase, PsycINFO, and CINAHL up to July 5, 2024 (Table S1) and hand-searched reference lists of included studies. Pairs of reviewers independently screened studies to identify observational studies reporting on depressive symptoms, anxiety symptoms, or sleep disturbances in patients with CU. We extracted study design, participant characteristics, and outcome prevalences at the lowest threshold and earliest timepoint. We conducted DerSimonian-Laird random-effects meta-analyses of proportions using the STATA (v18) metan function to pool logit-transformed proportions and explored sources of heterogeneity through subgroup analysis and meta-regression. We assessed study risk of bias using a validated tool for studies of prevalence (Table S2), quantified heterogeneity using Cochran's Q test and the I2 statistic, assessed publication bias using funnel plots and Egger's tests, and evaluated the certainty of the evidence using the GRADE approach. We screened 12,508 unique citations, of which 42 studies were included, reporting on 4,471 patients from 19 countries with a median mean age of 41.31 years and a median of 70.60% females (Figure 1; Table S2). From 35 studies (n = 3,871), the pooled prevalence of depressive symptoms was 37.0% (95% CI: 30.4–44.3, low certainty) with serious heterogeneity (I2 = 93.7%, p < 0.001; Table 1; Figure S1). From 31 studies (n = 3,703), the prevalence of anxiety symptoms was 46.1% (95% CI: 38.6–53.7, low certainty) with serious heterogeneity (I2 = 93.9%, p < 0.001; Table 1; Figure S2). From 10 studies (n = 1,062), the prevalence of sleep disturbances was 53.0% (95% CI: 36.9–68.8, very low certainty) with serious heterogeneity (I2 = 94.6%, p < 0.001; Table 1; Figure S3). Subgroup analyses found that anxiety symptoms were more prevalent in patients from the Eastern Mediterranean region and sleep disturbances were more prevalent in the Eastern Mediterranean and European regions (Tables S3 and S4). Meta-regression analyses revealed significant positive associations between urticaria severity and the prevalence of depressive symptoms (p = 0.003; adjusted R2 = 46.6%) and anxiety symptoms (p = 0.031, adjusted R2 = 26.3%) (Table S5). No publication bias was detected (Table S6 and Figures S4–S6). The most common screening tools were the Hospital Anxiety and Depression Scale (depressive symptoms n = 18, 51%; anxiety symptoms n = 18, 51%) and Pittsburgh Sleep Quality Index (n = 6, 60%). 37.0 (30.4–44.3) Low Due to very serious inconsistencya 46.1 (38.6–53.7) Low Due to very serious inconsistencyb 53.0 (36.9–68.6) Very low Due to serious risk of bias and very serious inconsistencyc Limitations of our review largely stem from the available evidence. The significant heterogeneity across all outcomes limits the generalizability of pooled estimates. Additionally, we could not stratify our analyses by treatment status due to insufficient reporting in the included studies. Given our finding that urticaria severity is associated with the prevalence of depressive and anxiety symptoms, treatment status may be a key source of heterogeneity. This review quantifies the high rates of mental health symptoms in patients with CU, highlighting a need for allergists to actively consider the psychological effects of CU in clinical practice. Psychological interventions and patient education should be integrated into treatment plans, and patients' quality of life should be monitored. Future research to develop primary prevention, detection, and management strategies is needed to address the mental health needs of patients with CU. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request. Appendix S1 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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