Psoriasis, Psoriatic Arthritis Linked to Depression, Suicidality
Abstract
Experts call for screening patients and working with dermatologists to ensure continuity of care.
People who have psoriasis are roughly 1.5 times more likely to have symptoms of depression and nearly two times more likely to experience suicidal ideation compared with people who do not have the condition, a study in General Hospital Psychiatry has found. A separate study published in the Journal of the Academy of Consultation-Liaison Psychiatry found that people who had psoriatic arthritis in addition to psoriasis are nearly three times more likely to have depression than those who have psoriasis only.
Pro-inflammatory markers that are elevated in psoriasis have also been found to be elevated in depression, anxiety, and schizophrenia, says Thea Hedemann, M.D.
Taken together, these studies add to the growing body of evidence to recommend screening for depression and suicidality in patients who have psoriasis with or without psoriatic arthritis, said Mohammad Jafferany, M.D., who is a clinical professor of psychiatry and behavioral sciences at Central Michigan University College of Medicine and CMU Medical Education Partners in Saginaw, Mich., and past president of the Association for Psychocutaneous Medicine of North America.
“The psychological profile of psoriasis patients encompasses impaired quality of life; low self-confidence; [higher risk of] anxiety and depression; poor treatment adherence; and higher rates of sexual dysfunction, sleep disturbances, stigmatization, and suicidal ideation,” said Jafferany, who was not involved in either study. “Mandatory depression screening and suicidal evaluation is highly recommended in patients with severe psoriasis, particularly psoriatic arthritis.”
Yet there are no standard procedures for screening these patients, Thea Hedemann, M.D., lead author of the study in General Hospital Psychiatry told Psychiatric News. She is a psychiatry resident completing her training at the University of Toronto, based at the Centre for Addiction and Mental Health.
“Despite the high rates of mental illness in psoriasis patients, there are no universally accepted guidelines, screening tools, or referral pathways for these patients,” Hedemann said. “The goal of our research was to better understand the association between psoriasis and mental illness as well as to provide guidance for clinicians.”
Hedemann and colleagues analyzed data from 24 studies, focusing on systematic reviews; meta-analyses; and randomized, controlled trials. Most of the studies used standardized questionnaires such as the Hospital Anxiety and Depression Scale (HADS) or the Beck Depression Inventory to identify patients with psoriasis who also had depression. The data revealed that patients who have psoriasis are not only more likely to experience depressive symptoms and suicidal ideation than their peers without psoriasis, but also have higher rates of anxiety and schizophrenia.
Patients with psoriatic disease and mental illness could benefit from a continuous, structured partnership between liaison psychiatric and dermatological services, ideally within integrated psychodermatology services, says Georgia Lada, M.D.
“Psychological and social factors may explain part of the association [between psoriasis and mental illness], but there could also be a biological basis for this association,” Hedemann explained. “Psoriasis is an autoimmune condition that causes inflammation in the body. Pro-inflammatory markers that are elevated in psoriasis have also been found to be elevated in depression, anxiety, and schizophrenia.”
In the second study, Georgia Lada, M.D., consultant psychiatrist and a doctoral researcher at the United Kingdom’s National Institute for Health Research Biomedical Research Centre (University of Manchester), and colleagues conducted a survey of 219 adults aged 18 to 65 who were attending specialist psoriasis and psoriatic arthritis clinics in Greater Manchester. Of the 219 patients, 84 had psoriatic arthritis. The patients completed several questionnaires, including the HADS and the Snaith-Hamilton Pleasure Scale, and answered questions about their medical and psychiatric history. Patients with psoriatic arthritis also completed the Psoriatic Arthritis Impact of Disease Questionnaire.
Even when adjusting for other medical problems, those with psoriatic arthritis were 2.92 times more likely to have depression than those with non-arthritic psoriasis.
“The association of psoriatic arthritis with depression seems to exist independently of the underlying skin disease or other comorbid conditions,” Lada told Psychiatric News.
Nearly one-third of all patients in the study had experienced active suicidal ideation at some point in their lives, one-fifth had planned suicide, and nearly one-tenth had attempted suicide. Lada said these findings highlight the need to monitor patients with psoriasis in tertiary care for suicidality.
Interconnected Conditions Need Interconnected Care
Psychiatrists will most often encounter patients who have psoriasis with or without psoriatic arthritis after these patients have been referred for mental health care. However, the experts say that a proactive approach could reach more patients and result in better care.
“It is important to ensure that patients with both mental health disorders and psoriasis have adequate medical follow-up and support,” said Hedemann. “Sometimes this means liaising with [patients’] other health care professionals or facilitating referrals to dermatology specialists.”
Lada said that despite efforts to increase mental health awareness in dermatology, dermatologists may not feel confident asking patients about depression and suicidal ideation. She added that patients whose conditions flare up in response to stress may not always address their mental health problems either during or after treatment for their flares.
“Given the high prevalence of ... psychiatric comorbidity, we believe that these populations could significantly benefit from a continuous, structured partnership between liaison psychiatric and dermatological services, ideally in the context of integrated psychodermatology services,” Lada said.
Jafferany agreed, adding that psychiatry liaison services and psychodermatology clinics are vital in the holistic treatment of patients who have mental health conditions and psoriasis with or without psoriatic arthritis.
“Working knowledge of basic psychopharmacology by dermatologists is always helpful as these patients may feel stigmatized and refuse to see a psychiatrist,” Jafferany said. “Supportive psychotherapy and cognitive-behavioral therapy in combination with antidepressants and dermatological treatment [have proven] to be beneficial.”
The experts have one final tip for psychiatrists who treat patients who have psoriasis: Be cautious when prescribing lithium, as it can worsen psoriasis and induce psoriatic flares.
The study in General Hospital Psychiatry was supported in part by the University of Toronto. The study in the Journal of the Academy of Consultation-Liaison Psychiatry was supported by the NIHR Manchester Biomedical Research Center. ■
