Depressive Symptoms and Psoriasis Systemic Treatment

A study¹ published in the Journal of Comparative Effectiveness Research aimed to evaluate the presence of depression as a burden on patients with psoriasis when responding to systemic therapies and to define the baseline characteristics of patients with depressive symptoms who have improved on systemic treatment.

Researchers analyzed patients enrolled in the CorEvitas (formerly Corrona) Psoriasis Patient Registry through September 2018 by comparing changes from enrollment to the 12-month visit. Their results showed that a history of depressive symptoms does not indicate a differential response to systemic treatment and that patients had worse baseline characteristics despite improvement in depressive symptoms.

To discuss her study and its results, The Dermatologist met with lead author Neda Shahriari, MD, a board-certified dermatologist at Brigham and Women’s Hospital in Boston, MA.

How can rheumatologists best screen patients for depression in the context of regular office visits? Is there a simple tool available for them to use?

I think both the rheumatologist and the dermatologist should play a role in screening these patients. And I recognize the fact that a clinic can be a really busy atmosphere. One tool that I have thought about, because I actually gave some talks in this regard, is the Patient Health Questionnaire-2 (PHQ-2), which is a really simple, easy tool to use to screen our patients for depression. It asks patients to quantify for us the frequency of two basic symptoms: 1. Whether they have had a loss of interest in doing things that they are normally doing and 2. Whether they have been feeling sad, depressed, and so on. Depending on how they score on that questionnaire, you can see who is at a higher likelihood of having depression.

Now, of course, there are other more extensive tools too. There is the Patient Health Questionnaire-9, and it goes through a lot more questions with these patients. Still, I figured if we wanted to really be able to implement this, we need an easier tool given how busy clinic is. The PHQ-2 would be an excellent tool just to do the preliminary screen to see who may potentially be impacted by this.

How can physicians work with their patients to manage both depressive symptoms and psoriasis? Is this a situation in which they should collaborate with a colleague in mental health to whom they can refer patients who show signs of depression?

Basically, my feel for how a patient with psoriasis should be managed is that it should be a multidisciplinary effort. It should be the dermatologist weighing in and the rheumatologist, as well as our mental health specialist colleagues. When it comes to the side of the dermatologist or the rheumatologist when trying to manage the more psoriasis or psoriatic arthritis piece, what is really important is their awareness of whether a patient does have potential depressive symptoms. I say this because it is more than just them being able to refer the patient to a mental health specialist colleague, but it also can impact how we treat these patients. This has been shown in several studies that have recently come out where patients with psoriasis and depression who have been on biologic treatment have improvement in their depression.

What we are realizing is that these systemic treatments can actually help with the depressive symptoms. Sometimes in the dermatology community we may think, "Oh, if a patient has extensive body involvement of their psoriasis, that is what warrants them going on a biologic medication or a systemic medication," but what we are actually finding is that if a patient has depressive symptoms, they actually may benefit from being on a systemic therapy as well.

The other piece is that, even with the dermatologist and the rheumatologist deciding on a treatment, it is going to be really important to have our mental health specialist colleagues weigh in because it could be particularly useful for our patients. It is appropriate for them to be on treatment for their depression. We did another study using the CorEvitas Psoriasis Patient Registry,² where we looked at patients who have psoriasis, a history of depression, and who were on antidepressants versus those who have psoriasis and a history of depression who were not on antidepressants. What we found is that those who were on antidepressants not only received help with the depressive symptoms, but actually had improvement in their psoriasis itself. Which is really interesting because you wonder why would an antidepressant therapy help? Not that we are trying to make a causal link, but if we were to theorize, why would someone on an antidepressant have more of an improvement in their psoriasis? It is possible that, as part of those psoriasis processes, patients can get itchy and when they scratch their skin, they can develop cauterization phenomena, which causes more psoriasis to appear.

An antidepressant can actually help stop this itch-scratch cycle because it can decrease the amount of pruritus that is there and the amount of itch that is there. So, these patients potentially could have some benefit from that standpoint as well. Overall, I think it would be excellent just to use this multidisciplinary approach for our patients with psoriasis.

Listen to her discussion from our podcast here.

References
1. Shahriari N, Mattessich S, Lin TC, et al. Assessing the change in disease severity based on depressive symptoms in real-world psoriasis patients. J Comp Eff Res. 2021;10(16):1215-1224. doi:10.2217/cer-2021-0106

2. Shahriari N, Lin TC, Litman HJ, Dube B, McLean RR, Shahriari M. Characterization of real-world patients with psoriasis and without a history of depression: the Corrona Psoriasis Registry. J Am Acad Dermatol. 2021;84(5):1444-1447. doi:10.1016/j.jaad.2020.06.994