The Psychiatric Burden in Alopecia Areata: A Propensity-Matched Cohort Study

Abstract

Introduction: Alopecia areata (AA) is a chronic autoimmune hair disorder with a substantial psychosocial impact, yet contemporary, population-scale estimates of incident psychiatric comorbidity are limited. To quantify the risk of incident psychiatric disorders in adults with newly diagnosed AA versus matched controls, we assessed sex differences, and explored pre- versus post–coronavirus disease 19 (COVID-19) patterns. Methods: We conducted a multinational, retrospective cohort study using de-identified electronic health records (2015–2025) from TriNetX. Adults with AA (ICD-10 L63) and at least 6 months of prior records were matched 1:1 to general-examination controls without AA. Propensity score matching balanced age, sex, and major comorbidity domains. For the psychiatric outcomes, ICD-10 codes were used. Risk ratios (RRs), and time-to-event with hazard ratios (HRs) analyses were estimated overall, by sex, and by pre/post–pandemic epoch; multiple sensitivity analyses tested robustness. Results: After matching, 57,389 patients with AA and 57,389 controls were analyzed. AA was associated with a markedly higher risk of any incident psychiatric disorder versus controls (RR = 4.49, 95% CI 4.30–4.70). The largest relative increases were seen in depression and anxiety, with smaller but notable rises in insomnia/parasomnia and substance use disorders. Suicidal behaviors and psychotic disorders also increased but remained rare. Women experienced a higher overall psychiatric burden—particularly depression, anxiety, and eating disorders—while men showed relatively higher rates of substance use. After COVID-19, the most significant increases were in anxiety, insomnia/parasomnia, eating disorders, self-harm, and suicide. These results were consistent across various sensitivity analyses. Conclusions: Adults with AA have a significantly higher risk of experiencing various new psychiatric disorders, especially among women and following the COVID-19 pandemic. Regular mental health screening, prompt referrals, and combined dermatology–psychiatry care could enhance outcomes. Further prospective research, including assessments of disease severity and patient-reported data, is necessary.