Psoriasis and depression appear inextricably linked, whether directly or indirectly and with causation or exacerbation potentially running both ways. Some clinicians have proposed using antidepressants that act on the serotonin system to treat psoriasis and others have suggested conducting a psychiatric evaluation for every patient prior to administering dermatological treatments for psoriasis.

Suicidal Thoughts and Psoriasis

An analysis of large epidemiological studies into psoriasis and mental health was carried out by Rabin, et al (2012), who found that suffering with psoriasis adversely affected quality of life, regardless of the degree to which the psoriatic lesions spread across the body. More than three quarters (79%) of patients with psoriasis reported a negative impact of the disease on their quality of life, and 24-51% reported suffering from depression (a significantly higher percentage than in the general population). Shame and embarrassment over the appearance was reported by almost all psoriasis patients (89%) and around one in ten patients said that they had an active desire to be dead or had suicidal ideation.

Stress and Psoriasis Significantly Linked

Other psychological issues experienced by patients with psoriasis, as reported by Rabin, et al, included a lack of confidence (42%) and family friction (26%), along with alcohol abuse and addiction in 18% of patients and a stressful life event associated with their psoriasis in 10-90% of cases. The figures for psychological disorders in children were even more troubling as there was a 32-250% increase in risk of anxiety in children with psoriasis, as well as a 25-47% increase in risk of developing any psychiatric disorder.

Did You Have a Psychiatric Assessment Before Receiving Corticosteroid Therapy?

These kinds of reports make it obvious why Barrimi, et al (2013), suggest carrying out psychiatric assessments on all patients prior to treating psoriasis and other dermatological conditions with drugs that may affect mental health. Their primary concern was the iatrogenic effects of long-term corticosteroid use as regards anxiety and depressive disorders. What they found was an increased incidence in such psychological problems in the early weeks of treatment with corticosteroids for skin disease. They also noted that these disorders are often missed and underestimated, with consequences for the patients’ mental health and prognosis in terms of their skin condition. Patients included in this study were being treated with corticosteroids for either lupus, deep pemphigus, bullous pemphigoid or dermatomyositis.

Do Corticosteroids Increase Risk of Suicide in Skin Disease?

Again, using the BDI, along with the Hamilton Anxiety Scale (HAS) and the Mini International Neuropsychiatric Interview (MINI), the researchers followed patients for a year to determine prevalence of anxiety and depressive disorders in those with chronic skin diseases for whom corticosteroid therapy was prescribed long-term. Fifty-four patients were included in the study and 27% had anxiety of depressive disorders; 16% were depressive disorders, 11% anxiety disorders. Depression was assessed as moderate according to the BDI in 67% of cases, severe with suicide attempts in 22% and mild in 11%. Anxiety was mild in 33% of cases, and moderate in the remaining patients with the disorder.

Older, Female Patients with Deep Pemphigus at Greatest Risk of Depression/Anxiety

Patients older than forty, female patients and those being treated for deep pemphigus were found to have the highest incidence of anxiety disorders or depressive disorders. In addition, the dose of corticosteroids was found to be a risk factor for such disorders, as was previous psychiatric history. Patients found to have such disorders during the study were given appropriate psychiatric help whilst continuing to be treated for their skin condition. Their prognosis was good, suggesting that those already using corticosteroids long-term or who are commencing such therapy may be benefitted by psychiatric evaluation in order to identify risk factors and begin complementary psychotherapy promptly.

Antidepressants for Skin Disease?

It may even be that such psychotherapy helps improve skin conditions sufficiently that patients are able to reduce their dosage of corticosteroids or stop such treatment altogether. Research set to be published next month suggests that psoriasis and serotonin are linked even at the level of the skin itself, meaning that antidepressants could become a common therapy for psoriasis and other skin disorders.

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