The Mental Health and Psoriatic Disease Connection

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The role of mental health in psoriasis remains an emerging area in dermatology with significant implications for quality of life. In a webinar hosted by the National Psoriasis Foundation (NPF), Vanessa Cutler, MD, MPH, a clinical assistant professor of psychiatry at New York University, focuses on the association between psychiatric illness and skin disease. For example, in patients with psoriasis who may experience depression, levels of the inflammatory markers IL-6, IL-18, and IL-17A are elevated.

Psychiatric Comorbidities
Adult and pediatric patients with psoriasis are at higher risk for having psychiatry comorbidities, including depression and anxiety. During the webinar, Dr Cutler noted that “at least 20% to 30% of patients with psoriasis experience depression.” Untreated depression can hinder treatment of skin disease. Similarly, “over 30% of patients with psoriasis believe that stress plays a role in flares,” shared Dr Cutler. Often, treating the skin disease can in and of itself reduce stress.

Patients with psoriasis may also experience feelings of disfigurement over their lifetime. The average age of diagnosis is 33 years old. Thus, the appearance of visible skin lesions can lead to social and occupational impairment for decades. Yet, it is not just the patient who is affected; psoriasis can affect both patients and their partners. It is therefore important for physicians, patients, and the public to recognize the burden of psychiatric illness in psoriasis.
 

Screening and Referrals
In dermatology clinics, screening for psychiatric comorbidities is typically not performed. Factors that contribute to lack of screening include limited time, focus on treating the skin, and social stigma. While patients with psoriasis tend to rank embarrassment over their appearance as their top concern on quality-of-life surveys, skin care providers rank this metric of their patients much lower.

Fortunately, screening tools in psoriasis exist to identify patients who may be at risk for mental health comorbidities. Some tools, such as the Psoriasis Disability Index, are correlated to a Psoriasis Area and Severity Index (PASI) score. Examples of not correlated or not well correlated tools include the 12-item Psoriasis Quality of Life Questionnaire and the Dermatology Life Quality Index.

Even though patients may resist referral to a mental health professional for a skin disorder, it should still be offered if need-ed. Primary care is another setting where mental health screening can be performed.

Treatment Considerations
Medical treatment of psoriasis and psychiatric comorbidities remains an active area of research. Biologic therapies like IL-17 and IL-23 inhibitors may help decrease symptoms of depression. It is thought that these therapies limit specific inflammatory molecules from reaching the brain. The role of psychotropic medications in psoriasis has not been well-studied. In patients with anxiety and posttraumatic stress disorder, there is some evidence that selective serotonin reuptake inhibitors decrease inflammation.

Several other psychiatric modalities of treatment also exist. Cognitive behavioral therapy can reduce the stigma of psoriasis while giving patients more autonomy over their illness. Acceptance and commitment therapy can help manage the unpredictability of psoriatic flares and feelings of shame and grief. This type of therapy requires putting distance between oneself and negative thoughts. Habit reversal training can facilitate breaking the itch-scratch cycle.

Conclusion
It is essential for health care providers to understand the connection between psoriatic disease and mental health, and how to support patients who may be struggling with both. To learn more, you can watch Dr Cutler’s webinar presentation at https://www. psoriasis.org/cme-library/mental-health-connection.

Visit https://www.psoriasis.org/cme-library for more NPF continuing medical education webinars.

Reference
Cutler V. The mental health and psoriatic disease connection. National Psoriasis Foundation. September 14, 2023. Accessed January 12, 2024. https://www.psoriasis. org/cme-library/mental-health-connection