INTRODUCTION
Atopic dermatitis (AD) typically develops in infancy and exhibits a cycle of exacerbation and remission. The disease can persist into adulthood [1,2]. AD prevalence among Korean adolescent was 22% from 2007 to 2017 [3]. The chronic skin itching caused by AD is most severe at dawn when the body’s steroid concentration decreases, significantly affecting sleep quality, and adolescents with AD experience more sleep disorders [4-6]. Adolescents with AD experience negative social and psychological changes due to chronic itching and skin changes caused by repeated inflammation. Previous studies have reported a higher prevalence of psychosocial and psychiatric comorbidity among adolescents with AD [7-9].
Adolescence is a period of significant physical and psychological changes that involves forming a sense of identity and values. Consequently, adolescents are influenced by their environment in ways that are different from adults. If the problems and conflicts in their home, school, or society are not satisfactorily resolved, adolescents may experience emotional problems including stress, depression, conduct disorders, defiance disorder, or even suicide. Democratic People’s Republic of Korea (North Korea) defectors are known to face mental health problems due to cultural adaptation stress, such as political and cultural differences, identity crisis, and economic difficulties [10,11]. AD is expected to pose both mental and physical challenges for adolescent defectors. Additionally, North Korean adolescent defectors are more prone to experience family breakdowns or physical and psychological stress during the migration process. Until the mid-1990s, it was nearly impossible for North Korean defectors to move to Republic of Korea (South Korea) with their families. However, since the 2000s, the rate of reunification with families who had already entered South Korea has increased due to long-term stays in China or other countries. By 2020, 42.7% of North Korean defectors were reunited with their families [12].
Suicide is one of the leading causes of death among adolescents in many countries [13], including South Korea, and a suicide rate was 7.1/100,000 persons among South Korean teenagers in 2021 [14]. The suicide rate for people aged 15-34 years in East Asia, including South Korea, China, Hong Kong, Japan, Organization for Economic Co-operation and Development (OECD) countries, the Asia-Pacific region, New Zealand, and Thailand, ranged from 10-19/100,000 persons in 2011 [15]. The suicide rates (per 100,000 persons) among adolescents in OECD countries from 1990-2015 were as follows: >15 in New Zealand, Iceland, Latvia, and Estonia; 5-10 in Canada, Poland, Luxembourg, Austria, Finland, United States, Australia, Chile, South Korea, Ireland, Japan, Mexico, Switzerland, Belgium, and Sweden; <5 in Slovenia, Denmark, Germany, Czech Republic, Hungary, Netherlands, Slovak Republic, France, Norway, United Kingdom, Turkey, Spain, Portugal, Italy, Israel, and Greece [16]. Unfortunately, we were unable to determine the suicide rates for North Korean adolescents. Data from the World Health Organization in 2019 indicated a suicide rate of 9.4/100,000 person in the entire population of North Korea and 28.6/100,000 person in South Korea [17].
Additionally, adolescents with AD have lower subjective health status, experience more stress, depression, anxiety, and insufficient sleep compared with adolescents without AD [3]. Adolescents with AD in South Korea were more likely to show stress, experience depression, and exhibit suicidal behaviors such as suicidal ideation [18], have a suicide plan [19], or have made a suicide attempt [3]. Adolescents with chronic physical conditions, especially during period of rapid physical, psychological, and social change, may be at a greater risk for developing chronic mental health conditions [20]. In other words, adolescents with AD must consistently manage their lifestyle to mitigate the negative effects of AD on daily lives. However, few studies have examined the association between suicidal behavior and AD in North Korean adolescent defectors. We hypothesized that North Korean adolescent defectors and adolescents with South Korean parents would show a significantly high risk of AD in relation to suicidal behaviors such as suicidal ideation, suicide plans, and suicide attempts. To test the hypothesis, we assessed the association between AD and suicidal ideation, suicide plans, and suicide attempts in North Korean adolescent defectors and adolescents with South Korean parents after adjusting for general characteristics and health behavioral factors.
METHODS
The Korea Youth Risk Behavior Survey from 2011 to 2019 (KYRBS VII-XV)21 was conducted by the Korea Institute for Health and Social Affairs for the Korean Ministry of Health and Welfare. The sample group from KYRBS VII-XV included middle and high school students in each grade from 2011 to 2019, selected through stratified random sampling by geographical area. There were 2,683,547 primary sample students from 5,611 schools. Of these, 423 subjects who were descendants of North Korean defectors and 540,265 adolescents with South Korean parents participated in the health behavior survey. We analyzed data from subjects aged 12 to 18 years old with weighted variables (n=540,688). We assigned a weight factor to each subject based on demographic and geographical characteristics, so representative estimates of the entire Korean middle and high school student population could be calculated.
North Korean adolescent defectors
Adolescent defectors are people who have left North Korea and entered South Korea during their adolescent period. The term “North Korea defector” is an official designation used by the Korean government for people who have escaped from North Korea and have not acquired a foreign nationality after leaving North Korea. The definition of adolescent defectors is similar to that of their father or mother as residents escaping North Korea. In this survey, adolescents were considered defectors if their father or mother were born in North Korea. However, it is unknown whether the surveyed subjects were born in North Korea or South Korea.
Adolescents with South Korean parents
The group of adolescents with South Korean parents was defined as those whose parents were born in South Korea, regardless of whether the parents were ethnically Korean. Thus, this study focused on children with at least one parent born in either North or South Korea.
AD
AD was defined as having received a medical diagnosis of eczema or prenatal fever from birth until the survey date.
Suicidal behaviors
Suicidal ideation was defined as a person having been deeply considered at risk for suicide in the last 12 months based on interview responses. Having suicide plans was defined as a person having made a plan for suicide in the last 12 months based on interview responses. A suicide attempt was defined as a person having ever attempted suicide in the last 12 months based on interview responses.
Questions: “Have you seriously considered suicide in the past 12 months?”, “Have you made a specific plan to commit suicide in the last 12 months?”, and “Have you attempted suicide in the last 12 months?”.
Answer: “Yes, I have” or “No, I have not.”
Depression
Depression was defined as a person reporting that they felt sad or desperate enough to quit their daily life activities for at least two weeks in the last 12 months based on interview responses.
Question: “Have you felt so sad or hopeless that you stopped your normal daily activities for two weeks in the last 12 months?”.
Answer: “Yes, I have” or “No, I have not.”
General characteristics and health behaviors
The general characteristics and health behavior survey questionnaires included the following variables: Instead of age, grades 7-12 (G7-G12) for boys and girls were used because only people aged 12 to 18 years old were included in this survey. The amount of sleep they typically receive on weekdays and weekends was separately calculated by asking the following question: “What time did you usually go to bed and wake up in the past seven days?”. Subjective health status was classified as good or not good using following question: “What do you think about your general health condition?”. Physical activity was defined as exercising for more than three days on the playground or in the gym in the past seven days. Subjects were classified as smokers if they had smoked at any point in their life by the survey date, and as drinkers if they had consumed alcohol at any point in their life by the survey date. We classified current living situation into two categories: “living with family” or “not living with family.”
Statistical analyses
Differences in general characteristics, health behaviors, suicidal ideation, suicide plans, suicide attempts, and AD between adolescent defectors and South Korean adolescents were examined using Student’s t-test or the chi-squared test. Multiple logistic regression analysis was used to determine the association between group (adolescent defectors vs. South Korean adolescents) as an independent variable and suicidal ideation, suicide plans, and suicide attempts as dependent variables after adjusting for grade, sex, depression, subjective health status, smoking, drinking, current living situation, and AD in the overall study sample. Also, we evaluated the association between AD as an independent variable and suicidal ideation, suicide plans, and suicide attempts as dependent variables after adjusting for grade, sex, depression, subjective health status, smoking, drinking, and current living situation in the adolescent defectors group and the South Korean adolescents group, respectively. All analyses applied sample weights proposed by the Korea Institute of Health and Social Affairs. All analyses were performed using SAS software (version 9.4 for Windows; SAS Institute Inc., Cary, NC, USA). A two-tailed p-value <0.05 was considered statistically significant for all comparisons.
Ethics
The study was approved by the Institutional Review Board (IRB) of Samsung Medical Center (IRB file no. 2022-04-108), and informed consent was waived due to the minimal risk posed to the subjects. The waiver of consent does not have an adverse effect on the rights or well-being of the study participants, and obtaining consent within the research timeframe was practically impossible. There is no reason to presume the subjects would refuse to consent, and even without consent, the risk level for the subjects is extremely low.
RESULTS
The proportion of grade-9 and grade-12 participants was higher in adolescent defectors than in South Korean adolescents (p=0.027). The proportion of boys was higher in adolescent defectors (61.7%) than in South Korean adolescents (54.5%) (p<0.001). The adolescent defectors group had poorer subjective health (10% vs. 6%), smoked more (47% vs. 18%), drank more (60% vs. 43%), lived with family less frequently (56% vs. 96%), and were more than twice as likely to have suicidal ideation (30% vs. 14%), a suicidal plan (23% vs. 5%), made a suicidal attempt (19% vs. 3%), and depression (42% vs. 27%) compared with the South Korean adolescent group (p<0.001). The amount of sleep was longer in Korean adolescents than in adolescent defectors (p<0.001). The distributions of AD were higher in South Korean adolescent than in adolescent defectors (p<0.001) (Table 1).
Tables 2-4 shows the distribution of grade, sex, suicidal ideation, suicide plan, suicide attempt, depression, amount of sleep, subjective health status, physical activity, smoking, drinking, living with family in their current living situation, and AD by suicidal behavior in the overall study sample, adolescent defectors, and South Korean adolescents.
The adjusted odds ratio (aOR) for the adolescent defectors group compared with the South Korean adolescents group was 1.66 (95% confidence interval [CI]=1.30, 2.13) for suicidal ideation, 3.59 (95% CI=2.76, 4.66) for suicide plans, and 4.34 (95% CI=3.27, 5.75) for suicide attempt after adjusting for grade, sex, depression, subjective health status, smoking, drinking, current living situation, and AD. AD was also significantly associated with suicidal ideation and having a suicide plan. For adolescent defectors, AD was associated with having a suicide plan (aOR and 95% CI=2.26 [1.17, 4.35]) and having attempted suicide (aOR and 95% CI=3.10 [1.54, 6.27]) after adjusting for grade, sex, depression, subjective health status, smoking, drinking, and current living situation, but was not significantly associated with suicidal ideation. For South Korean adolescents, AD was found to be associated with suicidal ideation (aOR and 95% CI=1.09 [1.07, 1.11]) after adjusting for grade, sex, depression, subjective health status, smoking, drinking, and current living situation (Table 5 and Supplementary Table 1 [in the online-only Data Supplement]).
DISCUSSION
The increased risk for having a suicide plan and attempting suicide associated with AD was significantly higher in adolescent defectors, while suicidal ideation was insignificantly associated with AD. Previous studies have linked AD with suicidal behaviors [22,23], such as suicidal ideation [24,25], among adolescents. Most studies on AD and suicidal ideation in adolescents using the KYRBS were conducted without regard for multicultural factors in families [19,26,27].
In this study, the aOR for suicidal ideation, suicide plan, and suicide attempt was significantly higher in adolescent defectors compared with South Korean adolescents. The distribution of suicidal ideation, suicide plan, and suicide attempt in adolescent defectors was more than 2-6 times higher than in South Korean adolescents. There have been few studies on suicidal ideation, suicide plans, and suicide attempts among adolescent defectors in South Korea; however, in 2016, the prevalence of suicidal thoughts and behaviors among 300 adult defectors from North Korea at the Settlement Support Center for North Korean Refugees (Hana Center) in South Korea was higher than in the general population in South Korea [28].
Defectors are known to experience mental health problems due to acculturative stress involving political and cultural differences, identity crises, financial difficulties, and other factors during the process of escaping from one or more transit countries and after settlement in South Korea [29-31]. Nevertheless, North Korean defectors settle and live in South Korea society because of the social welcome they receive, the shared traditional culture and language between North and South Korea, and the social support system provided by both the government and non-governmental organizations. North Korean defectors and their children struggle to adapt to the liberal democratic society of South Korea that they have never experienced. However, this study highlights the seriousness of the higher distribution and aOR of suicidal ideation, suicide plans, and suicide attempts among adolescent defectors compared with South Korean adolescents (p<0.05). Although the distribution of AD in adolescent defectors was lower than in Korea adolescents, the group of adolescent defectors had poorer subjective health, smoked more, drank more, lived with their families less than half as much, and were more than twice as likely to have depression than the South Korean adolescent group (p<0.05). Allergies are caused by environmental exposures and stress, which can exacerbate symptoms of AD [32]. Stress affects immune responses associated with AD [33]. Patients with allergies often face psychological and social problems due to continuous treatment and management. Establishing healthy habits in adolescence is closely related to health habits in adulthood, so efforts to form and maintain healthy lifestyles from adolescence are emphasized to prevent chronic diseases and reduce burden in adulthood [34].
This study found higher risk for suicidal behavior among adolescent defectors who had depression or were living without family. Several previous studies have already reported an association between suicidal behavior and depression [35-37] as well as not living with family [38]. Smoking was associated with high risk for suicidal ideation [39,40] and suicide attempt [41,42], while drinking was associated with high risk for having a suicide plan [43]. Poor subjective health was the only factor that led to statistically significantly higher risk for suicidal ideation [44]. Interestingly, our study showed that the mean number of weekend sleeping hours for adolescent defectors was 5.92 hours. The group of adolescents who had a suicide plan had significantly shorter sleep time than the group without a suicide plan. However, both South Korean adolescents and adolescent defectors had a mean number of weekday sleeping hours of about 6.5 hours, and a mean number of weekend sleeping hours of around 8-9 hours. Compared to Korean adults, about 80% of young adults slept for 6-8.9 hours a day [45].
The issue we identified is that around 5%-6% of the adolescent defectors who were in the suicide plan and suicide attempt group had no suicidal ideation. Therefore, it is crucial for adolescent defectors to receive treatment for AD and to actively participate in counseling programs for depression to achieve emotional, physical, and spiritual health. They should also join community or school-based programs for smoking and drinking cessation, increase their physical exercise, and live with family, when possible, to achieve emotional and psychological stability. Consequently, we conclude that psychological health and social support should also be taken into account when treating South Korean adolescents and adolescent defectors with AD [19], because happiness during adolescence can impact life throughout adulthood [46,47].
This study had some limitations. First, due to the cross-sectional study design, it was difficult to explain the causality between AD and suicidal behaviors in adolescent defectors. Second, it is unclear from the data whether dermatological treatments have an impact on suicidal behavior [48,49]. Therefore, dermatologists should take steps to prevent suicide among adolescent AD patients [50,51]. Furthermore, the confirmation of association between AD and suicidal behaviors in this vulnerable population suggests that the clinical presentation of AD may represent a valuable opportunity for primary care physicians to initiate discussions about mental healthcare, which may otherwise be stigmatized or inaccessible in this population. Third, KYRBS is an anonymous survey in which respondents write their own answers, which may be incorrectly written or omitted, so the risk of an association between a current AD case and suicidal behavior may be either under- or overestimated. Fourth, the depression variable was measured in a single subjective simple sentence without using standardized tools. Furthermore, more comprehensive research is required from a cohort group comprising solely of adolescent defectors. This is an additional area where future research is necessary. One of the strengths of this study is the high degree of representation of all of Korean adolescents, with a response rate of over 95% from 2011 to 2019 [52,53].
In conclusion, based on a random sample of middle and high school students in South Korea, we found evidence that AD is associated with suicide plans and suicide attempts in adolescent defectors and with suicidal ideation in Korean adolescents. Given the significant impact of AD on psychologically and socially vulnerable people, it is crucial to implement effective prevention and management programs to prevent the escalation of suicidal ideation and plans into actual suicide attempts.
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