Depression Complicates Management of Psoriatic Disease

Jul 11, 2024

Photo Credit: Melitas

In a new study, researchers explore the relationship between psoriasis and depression, and how depression can be addressed with different forms of therapy.

Depression is increasingly recognized as a problematic comorbidity in psoriatic disease. During a special session at IFPA 2024, Dr. Wiebke Sondermann, MD, from the University Hospital Essen, in Germany, reviewed the link between depression and psoriasis and explored screening and therapeutic modalities.

Psoriatic disease is associated with a multitude of psychiatric comorbidities. Compared with the general population, patients with psoriatic disease tend to have a higher prevalence of depression, suicidal ideation, suicidal behaviour, anxiety disorder, alcohol, and nicotine abuse. Furthermore, stigmatization resulting from the skin manifestation of psoriasis is a strong predictive factor for depression (P<0.00001), with a greater effect in women than men. Depression also has an impact on disease management. “Depression makes it more difficult for patients to focus on the improvement of their skin disease and often impairs treatment adherence,” said Dr. Sondermann.

There might also be a link between depression and psoriatic disease beyond stigmatization. “In recent years, more has become clear about the close interaction between the skin, the psyche, the nervous system, and the immune system,” said Dr. Sondermann. Systemic inflammation is present in both skin disease and depression, “also referred to as the cytokine hypothesis.”

Furthermore, stress is the most important triggering factor in psoriatic disease. Participants with psoriasis enrolled in a questionnaire study reported stress as the most common factor triggering their disease (92%), followed by infections (33%).

For clinical practice, Dr Sondermann recommends the 2-question test with a positive response leading to a specialist referral: have you frequently felt rejected, sad, glum, or hopeless during the past month? and have you taken significantly less pleasure and joy in things that you otherwise enjoy doing, over the past month?. Treating physicians should also screen for alcohol abuse using the CAGE or AUDIT questionnaire.

Therapies for Psoriasis With Concomitant Depression

A large meta-analysis of immunomodulatory therapies (including anti-TNF and anti-IL-17/IL-23) in inflammatory diseases with comorbid depression showed a significant antidepressant effect compared with placebo (P=0.0006). Furthermore, an analysis based on the PSOLAR registry showed that biologics have an increased effect on depressive symptoms versus conventional therapy (HR 0.76; 95% CI 0.59–0.98). However, the EuroGuiDerm Guidelines recommend special care in the case of patients with a history of suicidal ideation by avoiding the use of acitretin, brodalumab, and apremilast¹⁰.

“Psoriatic disease is frequently associated with psychiatric comorbidities such as depression, and the observation of peripheral inflammation in both suggests that this may be a mechanism underlying the pathophysiological link,” said Dr. Sondermann. “Stress has been identified as a triggering factor both on the biological and clinical levels, and screening for comorbid mental illnesses should be implemented regularly. Patients with psychiatric comorbidities should receive appropriate interprofessional care involving mental health professionals.”