Recent research from the National Psoriasis Foundation (NPA) found that 1 in 3 people living with psoriatic conditions suffer from depression. Because stress can trigger the onset and flare-ups of psoriatic disease, experts in the field have emphasized the importance of screening for and managing depression in this population.
Ronald Prussick, MD, dermatologist at the Washington Dermatology Center, George Washington University School of Medicine and Fellow of the Royal College of Physicians of Canada, explained the impact depression can have on this population and how clinicians can address it with patients in the future.
HCP Live: Can you talk about the relationship between psoriatic disease and depression?
Prussia: Patients with psoriatic disease have systemic inflammation and this inflammation increases the risk of other comorbidities including: cardiovascular disease, non-alcoholic fatty liver disease and depression. The risk of comorbidity is generally correlated with the extent of psoriasis. The more severe the psoriasis, the higher the risk of having other comorbidities.
This is because the severity of psoriasis affects the amount of inflammatory cytokines in the body. It is estimated that about one third of patients with psoriasis may suffer from depression. Patients with depression may also have many of the same increased inflammatory cytokines as patients with psoriasis, such as: TNF Alpha, Interleukin 6, and Interleukin 17.
HCP Live: Does effective disease management have an impact on the prevalence of depressive symptoms in patients?
Prussia: We have data showing that you can improve depressive symptoms with treatment. An article was published from the PSOLAR registry, it showed that patients treated with biologics had about a 25% reduced chance of suffering future depression compared to just using traditional systemic therapies or phototherapy.
There is also data showing that patients with depression are less likely to achieve good skin clearance from TNF-alpha inhibitor treatments. This is thought to be because when you have depression in addition to psoriasis, you may have a high load of inflammatory cytokines.
HCP Live: What are some of the ways that depression presents in this population, and how can a clinician assess their patients if they are unsure?
Prussia: I think it’s best to ask your patient with psoriasis if their mood has really had an impact on their life. I ask them what things they would like to do that they can’t do right now because of their skin condition or mental state. You also want to ask about behaviors that might suggest an increased risk for depression or anxiety, such as smoking, alcohol abuse, an eating disorder, or drug use. I will also ask people what their appetite is and how well they sleep at night.
HCP Live: What are the intervention options when these conditions coexist?
Prussia: Give patients the support they need. We can send them to their treating doctor or refer them to a mental health specialist if necessary. Learning coping mechanisms is helpful. I also recommend 30 minutes of daily physical exercise, yoga, or meditation. Additionally, studies show that if we cleanse the skin, we can also improve depressive symptoms. Therefore, successful treatment of psoriasis can be beneficial.
HCP Live: Is there anything else you wanted to draw attention to?
Prussia: It is also important to know that patients who develop psoriasis at a young age are more likely to develop psychological problems. A Swedish study looked at 101 consecutive adult patients with psoriasis and assigned them personality, anxiety and depression scores.
They found that patients who developed psoriasis before age 20 or younger had a much higher risk of developing psychological problems later in life. Based on this, I think it is especially important to treat psoriasis aggressively in young patients.
Stress is a known trigger for psoriasis and when patients are stressed they produce cortisol. Patients with psoriasis do not produce as much cortisol as patients without psoriasis, which can trigger inflammation. When patients with psoriasis are stressed, they should learn to manage their stress using known stress relief therapies such as: yoga, meditation and breathing/mindfulness techniques. Patients can try to reduce their stress in different ways to prevent their psoriasis from kicking in.
For more information, visit the National Psoriasis Foundation website https://www.psoriasis.org/.