Home > Dermatology > IFPA 2024 > Comorbidities and Complications in Psoriatic Disease > Depression complicates the management of psoriatic disease

Depression complicates the management of psoriatic disease

Presented by
Dr Wiebke Sondermann, University Hospital Essen, Germany
Conference
IFPA 2024
Doi
https://doi.org/10.55788/99a9d3ae

Depression is increasingly recognised as a problematic comorbidity in psoriatic disease. During a special session at IFPA 2024, Dr Wiebke Sondermann (University Hospital Essen, 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, and alcohol and nicotine abuse [1]. Furthermore, stigmatisation 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 [2]. Depression also impacts 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 [1].

There might also be a link between depression and psoriatic disease beyond stigmatisation. “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” [1,3].

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%) [4].

For clinical practice, Dr Sondermann recommends the 2-question test with a positive response leading to a specialist referral: 1) have you frequently felt rejected, sad, glum, or hopeless during the past month?; and 2) have you taken significantly less pleasure and joy in things that you otherwise enjoy doing, over the past month? [5]. Treating physicians should also screen for alcohol abuse using the CAGE or AUDIT questionnaire [6,7].
Therapies for psoriasis with concomitant depression

A large meta-analysis of immunomodulatory therapies (including anti-TNF and anti-IL-17/IL-23) for inflammatory diseases with comorbid depression showed a significant antidepressant effect compared with placebo (P=0.0006) [8]. 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) [9]. 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 apremilast [10].

“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 [1]. “Stress has been identified as a triggering factor at both 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.”


    1. Sondermann W. Mental health in psoriatic disease. IFPA Conference 2024, 27–29 June, Stockholm, Sweden.
    2. Lakuta P, et al. Postepy Dermatol Alergol. 2017;34(1):36-41.
    3. Holsken S, et al. Acta Derm Venereol. 2021;101(11):adv00609.
    4. Mrowietz U, et al. J Eur Acad Dermatol Venereol. 2021;35(10):2027-2033.
    5. Radtke MA, et al. J Dtsch Dermatol Ges. 2015;13(7):674-90.
    6. O’Brian CP. JAMA. 2008;300(17):2054-6.
    7. Williams N. Occup Med (Lond). 2014;64(4):308.
    8. Wittenberg GM, et al. Mol Psychiatry. 2020;25(6):1275-1285.
    9. Strober B, et al. J Am Acad Dermatol. 2018;78(1):70-80.
    10. Living EuroGuiDerm Guideline for the systemic treatment of psoriasis vulgaris. Accessed on 3 July 2024 from https://www.guidelines.edf.one//uploads/attachments/clpb1puq520ysdtjr1vfe0bi1-26-depression-plus-mr-er-sep-2023.pdf

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