Psoriasis, Depression, and Suicidality
This article is a review and summary of “Psoriasis, Depression, and Suicidality,” published in SkinTherapyLetter in the June 2017 edition. Psoriasis is a serious concern that is more than a skin problem, and it’s important that the public be aware of the facts around psoriasis.
Context: About Psoriasis
Psoriasis is a very common condition affecting over 100 million people worldwide according to the World Health Organization1. Psoriasis is a complex disease that affects patients in a variety of ways, causing significant physical, social, and emotional burden. Open discrimination is still a problem in many parts of the world, which can affect employment opportunities, access to public facilities including health care facilities, and inhibits full participation in society that promotes well being2. Although most people think of psoriasis as a skin disease, psoriasis is linked with several other comorbidities:
- Cardiovascular health/Obesity
- Psoriatic arthritis
- Psychiatric problems
Skin diseases are often associated with increased risk of depression. As the skin is visible, it has an immediate impact and directly affect social interaction. Psoriasis, however, is the only disease associated with increased incidence of suicidal ideation3; in particular, one study reported suicidal ideation in the recent 2 weeks at 10%4.
Negative self-image and quality of life issues are significant, as psoriasis affects the skin, and is a visible condition. Social stigma and fear is also common, as many people may fear touching psoriasis patients due to fear of contagion5. Several studies have also pointed out that in high stigmatization diseases like psoriasis, the patients themselves may perceive the condition to be more negative than the public does6. Moreover, there may be evidence that biological changes that directly affect mood are altered in psoriasis patients; cytokines involved in inflammatory pathways may lead to depression. There are reports of treatments that potentially exacerbate psoriasis negatively affecting mood negatively7, and treatments that are directed toward psoriasis-related pathways like TNF inhibitors, improving mood8.
The Risk Factors:
The risk factors that were analyzed in this study were age, gender, and severity of disease.
Age: Psoriasis has two peaks of onset - first between the ages of 15-20, and second, between the ages of 55 and 609. Younger psoriasis patients, less than 20 years of age were more likely to have increased depression generally, and showed higher incidences of suicidal ideation, attempts, as well as completed suicides3.
Gender: Depression and suicidality is increased in both men and women. Some studies pointed at greater increase in depression in men among patients with severe psoriasis, but the results are not statistically significant, and there are conflicting data among studies. Similar to suicide statistics among the general population, women attempt more suicides, but men tend to complete suicides more often, likely due to the difference in the methods.
Severity: Although severe psoriasis is correlated with various medical comorbidities, including increase in mortality, there was no relationship between psoriasis severity and suicidality11.
Psoriasis: An Undertreated Problem
Studies show consistent patterns of undertreatment for psoriasis. Approximately 40% of psoriasis patients were not receiving treatment12; many patients with severe psoriasis were only receiving topical treatment. Dermatologists overwhelmingly agree that psoriasis burden is underestimated, and yet, over 50% of dermatologists say they will treat moderate to severe psoriasis with topical therapies alone13. Unsurprisingly, successful treatment of psoriasis, with controlled symptoms, resulted in decreasingly rates of depression and suicidality.
Importantly, depressive symptoms improved in trials for biologics: adalimumab, etanercept, and ustekinumab10. Current literature supports the use of biologics in the treatment of severe psoriasis. The development program for Brodalumab was stopped due to concerns with potential concerns with increased risk of suicidality, but it may be that the disease itself may be more causative rather than the treatment10.
Psoriasis is a serious condition that affect depression and suicide in ways that are appreciable and probably not fully understood. It’s important for health care providers to understand the impact of psoriasis on quality of life, as well as to understand relative risk of different patient profiles. Screening tools are proposed as a potential tool or protocol that dermatologists can use, to screen for psychological comorbidities in at risk patients like young patients with severe psoriasis involvement. Further research will be needed to understand the mechanisms by which psoriasis relates to psychological comorbidities, an aspect of psoriasis that is often underestimated.
The original article can be seen here: http://www.skintherapyletter.com/2017/22.3/1.html
2WHO Psoriasis report pg. 30
4Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol. 2006 Mar;54(3):420-6.
5Psoriasis is not a communicable disease.
7Afshar M, Martinez AD, Gallo RL, et al. Induction and exacerbation of psoriasis with Interferon-alpha therapy for hepatitis C: a review and analysis of 36 cases. J Eur Acad Dermatol Venereol. 2013 Jun;27(6):771-8.
8Menter A, Augustin M, Signorovitch J, et al. The effect of adalimumab on reducing depression symptoms in patients with moderate to severe psoriasis: a randomized clinical trial. J Am Acad Dermatol. 2010 May;62(5):812-8.
9Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005 Mar;64 Suppl 2:ii18-23; discussion ii4-5.
10Kurd SK, Troxel AB, Crits-Christoph P, et al. The risk of depression, anxiety, and suicidality in patients with psoriasis: a population-based cohort study. Arch Dermatol. 2010 Aug;146(8):891-5.
11Horn EJ, Fox KM, Patel V, et al. Are patients with psoriasis undertreated? Results of National Psoriasis Foundation survey. J Am Acad Dermatol. 2007 Dec;57(6):957-62.
12van de Kerkhof PC, Reich K, Kavanaugh A, et al. Physician perspectives in the management of psoriasis and psoriatic arthritis: results from the population based Multinational Assessment of Psoriasis and Psoriatic Arthritis survey. J Eur Acad Dermatol Venereol.2015 Oct;29(10):2002-10. This is understandable, of course, as cost of systemic therapy, access to insurance in the United States, and the risk of side-effects are all significant considerations that come into play.