Association of Resilience With Depression and Health-Related Quality of Life for Patients With Hidradenitis Suppurativa

Abstract

Importance: Hidradenitis suppurativa (HS) places a significant burden on the health-related quality of life (HRQOL) of patients, many of whom have depression. Resilience can play a role in mitigating the negative stressors, such as the symptoms of HS, on patients' mental health.

Objective: To investigate the correlation among resilience, depression, and HRQOL for patients with HS.

Design, setting, and participants: This cross-sectional survey study of 154 patients from 2 referral centers in the United States and in Denmark was conducted from June 1, 2016, to March 31, 2017. Patients were considered eligible if they were 18 years or older and had a visit for HS at 1 of the 2 referral centers in the past 2 years (from January 1, 2014, through December 31, 2016). Patients were excluded if they declined to participate, could not read or write in English or Danish, or had a cognitive disability that would preclude their understanding of the survey questions.

Main outcomes and measures: The survey instrument included 4 questionnaires: (1) a sociodemographic and clinical characteristics questionnaire, (2) the Brief Resilient Coping Scale, (3) the Hospital Anxiety and Depression Scale, and (4) the Dermatology Life Quality Index. The main outcome of interest was the HRQOL as measured by the Dermatology Life Quality Index.

Results: All 154 patients submitted a completed survey. The mean (SD) age of the participants was 40.93 (13.5) years; most participants were women (130 [84.4%]), and most participants self-identified as white (139 [90.2%]). The rate of depression among the patients in this study was comparable to those reported in previous studies; 55 patients (35.7%) were classified as having depression, and 32 patients (20.8%) had borderline depressive symptoms. Patient-rated HS severity and the depression score each independently estimated 27% and 10% of variation in HRQOL, respectively. The interaction term for resilience and depression was significant, indicating that resilience moderates depression. Analysis of the mediation effects of resilience was not significant, indicating that resilience did not mediate the association between depressive symptoms and HRQOL. The resilience score was significantly associated with depressive symptoms (regression coefficient a = -0.21; P < .001), and the depressive symptoms score (c = 0.637; P < .001) was significantly associated with lower HRQOL (c' = 0.644; P < .001). However, both the direct association (b = 0.033; P = .86) and the indirect association (a × b = 0.007; P = .87) of resilience with HRQOL were not significant.

Conclusions and relevance: Patients with higher resilience levels experienced a smaller decrease in HRQOL as depressive symptoms increased. Because the findings suggest that resilience can be taught, there is an opportunity to develop a resiliency training program and investigate its role in stress levels and depressive symptoms, as well as in HRQOL and disease activity.

Figure 1.. Mediation Analysis of the Association of Resilience With Depression and Health-Related Quality of Life (HRQOL)

The parameter estimates, b (SE; P value), are presented for the association of depressive symptoms with resilience (a = −0.21), the association of resilience with HRQOL after adjustment for depressive symptoms and hidradenitis suppurativa (HS) severity (b = 0.033), the association of depressive symptoms with HRQOL after adjustment for HS severity (c = 0.637), and the direct association between depressive symptoms with HRQOL after adjustment for resilience and HS severity (c′ = 0.644).

Figure 2.. Simple Slopes of the Moderation of Depressive Symptoms by Resilience on Health-Related Quality of Life (HRQOL)

Participants with low levels of resilience had a larger positive slope, indicating a larger decrease in HRQOL score for each unit increase in depressive symptoms score. In contrast, participants with high levels of resilience had a more shallow slope, indicating that as the depressive symptoms score increased, the decrease in HRQOL was lower. The areas of statistical significance of those where the 95% CIs (rectangular areas) do not overlap with 0 on the y-axis. Thus, only resilience levels higher than 4.62 points above the mean are not significant. Scores are centered on the mean.

Figure 3.. Areas of Statistical Significance for Moderation of Resilience on Depression

The Johnson-Neyman technique was used to determine the regions of significance for the moderation, for which the regression of the Dermatology Life Quality Index score on depression was significant. The shaded area is the 95% CI around the simple slope of depressive symptoms score. This shows that for participants with a resilience score less than 4.32 points above the mean, the simple slope of regression is significantly different from 0. In addition, resilience decreases the contribution of depression.