The link between mental health, psoriasis: What dermatologists need to know

Jonathan Silverberg, MD, PHD, MPH

Psoriasis is linked to many chronic health conditions, including diabetes, heart disease and depression, according to the National Psoriasis Foundation.

Research supports a significant association between depression and psoriasis. Despite this link, depression screening rates among patients with psoriasis is extremely low (1.2%), according to National Ambulatory Medical Care Survey data.

To learn more about this link, mental health treatment options for psoriasis patients and unmet needs, Healio spoke with Jonathan Silverberg, MD, PhD, MPH, director of clinical research, director of patch testing and associate professor, department of dermatology, The George Washington University School of Medicine and Health Sciences.

What do we currently understand about the link between mental health and dermatological conditions like psoriasis?

There’s a bidirectional relationship between psoriasis and mental health. We know that there is a strong mental health burden of psoriasis where psoriasis patients experience chronic disease, disability, itch, pain, cosmetic concerns and social isolation, all of which increase risk for symptoms of depression, anxiety, etc. That is, psoriasis can lead to high rates of mental health issues.

On the flip side, we know that stress can also be a trigger for psoriasis flare-ups as well. Psychosocial stress, depression and anxiety can all lead to worsening of disease; it can lead to a vicious cycle. Some patients might have one direction and one might have the other and one might have both.

We see higher rates of suicidality. Suicidality is an interesting problem because we often think of suicidality as always being related to depression and that’s not really the case. They often overlap, but there can be suicidality in patients even in the absence of clinical depression, and that has also been demonstrated with psoriasis.

How prevalent are mental health conditions in psoriasis? And what conditions are the most common?

Studies have shown that depression and anxiety are really the most common ones. It’s not terribly surprising because those are the most common ones in general, but they’re amplified with psoriasis, particularly with more severe disease. Prevalence rates vary between studies. However, meta-analyses have been done that showed higher rates of depressive symptoms, clinical depression and use of anti-depressants. Patients with moderate-to-severe psoriasis usually have high rates of mental health issues.

We published a study a few months ago that showed that psoriasis patients appear to have higher odds for psychiatric hospitalization. When we talk about mental health comorbidities, it’s one thing to say someone has some depression. It’s another level when they have severe depression. It’s a whole other dimension to say that they have a psychiatric emergency that warrants mental health hospitalization. Looking across nationwide hospitalization data in the United States, we found that patients with psoriasis had higher odds for hospitalization for a variety of mental health issues, including depression and anxiety. While those are the more common ones, we actually had higher odds for hospitalization for schizophrenia, substance use disorders, alcohol-related disorders, etc.

There is a whole continuum of mental health disorders that is implicated with psoriasis. When you consider the entire spectrum of mental health disorders and not just focus on depression and anxiety, the majority of more severe psoriasis patients have mental health symptoms or comorbidities.

Do mental health professionals often work collaboratively?

They do. I would say not enough. This is something that I’m a big fan of. More interdisciplinary care and better crosstalk between clinicians is needed.

There are several important aspects to the relationship between mental health disorders and psoriasis for clinicians.

On one hand, it’s important for the clinician to realize the impact psoriasis can have on patients. This is a reason for us to try to get tighter control and treat more aggressively. We’ve learned is that the relationship between psoriasis and mental health disorders is not an all or nothing situation. If we get these patients’ psoriasis better , we oftentimes can improve their mental health symptoms as well. This is not to say that psoriasis treatments are antidepressants, that’s not the point. However, when patients have depressive symptoms directly related to more severe skin disease, improving control of the skin disease improves their mental health much of the time.

On top of that, many young and middle-aged psoriasis patients don’t have a primary care doctor. The only thing that is bringing them in to seek care is their skin and the dermatologists may be the only doctor that a psoriasis patient sees for years. So, it’s imperative for dermatologists who are managing their psoriasis to say let me step back and treat the whole patient and not just focus on skin alone. We must recognize that if we do not screen for depression and suicidality, we will miss it to the detriment of our patients.

For most dermatologists, treating depression and suicidality is outside the scope of their practice, but even recognizing that it’s there and referring them to a mental health specialist or a psychiatric ER may improve the patient’s life – and would certainly improve their quality of life if nothing else. I think it’s very important for clinicians to recognize these issues.

Also, there are often access issues when it comes to mental health care in the U.S., which is a much broader issue than just psoriasis. It might be hard for patients to get in, there may not be a mental health specialist that the patient can get covered by their insurance company, and it may not actually be in the same hospital system or the same insurance network as the dermatologist. These can be barriers to crosstalk between dermatologists and mental health specialists. It’s imperative that we work as much as we can to improve that crosstalk because it could really reduce polypharmacy, improve patient’s quality of life and even save a patient’s life beyond their skin disease.

How can we increase this collaboration between dermatologists and mental health care professionals?

There is a growing interest in this, and in trying creative models, particularly with psoriasis doctors that may have mental health specialists on hand or at least within a referral network that are designed for exactly this. There are multispecialty practices that may have a staff psychologist or psychiatrist that patients can be referred to.

The first step is recognizing this is an issue and taking interest in it and recognizing that if I’m not asking it, then I’m missing it.

One of the struggles I face is that I screen patients all the time for depression or anxiety and I find it. I want to send them off to a mental health specialist, and patients often perceive a certain stigma and they say ‘Oh, I’m not crazy. I don’t need to see a shrink,’ and it’s important to say to them ‘No, I don’t think you’re crazy. This is part of your psoriasis.’ Recognizing that mental health symptoms can be part of the burden of skin disease and explaining to patients why they should be willing to seek care and accept care is just as important.

I think clinicians have to first take care about the association between psoriasis and mental health and recognize how important this is to patients.

What are the greatest unmet needs in addressing mental health issues in psoriasis patients?

There are definitely gaps that can be filled. For example, what is the best way of assessing mental health in clinical practice?

Most of our guidelines just recommend open-ended questions and leave it up to the clinician’s discretion. Even the eager clinician who wants to do this may ask, ‘what should I use here?’ We need more research on which validated instruments are best for assessing these patients, which are the most valid and which ones are feasible. It would help if we can have some of these tools built into an EHR to try to streamline it, so it doesn’t take a huge amount of time out of office practice.

There are a lot of different systemwide things that can be done to improve this, but we definitely need more research. It is clear from the existing research that the burden is there, but we also need to know what the best way is to treat these mental health concerns. For some patients, it is as simple as getting tight control of their skin disease to improve their mental health symptoms. Yet, for other patients, they may have a lingering or persistent mental health concern, and, at that point, they’re going to need treatment. What is the best way to treat those patients?

We could do a lot more interdisciplinary research to try to understand these points. As the data gaps tighten, that will inform treatment guidelines even more over time.

References:

• National Psoriasis Foundation. About Psoriasis. https://www.psoriasis.org/about-psoriasis. Accessed on January 15, 2020.
• Patel KR, et al. Dermatology. 2019;doi:10.1159/000499564.
• Singh P, Silverberg JI. Br J Dermatol. 2019;doi:10.1111/bjd.18629.
• Tohid H, et al. Skin Pharmacol Physiol. 2016;doi:10.1159/000448122.