Research suggests that patients with psoriasis and psoriatic arthritis (PsA) have a greater risk of depression, anxiety and, in some cases, substance abuse and dependence than the general population, yet symptoms often go unrecognized and untreated by medical professionals. Both psoriasis and PsA are associated with depression, with up to 30% of patients in either group experiencing depression, says Alexis Ogdie, MD, MSCE, director of the Penn Psoriatic Arthritis Clinic, Philadelphia, and associate professor of medicine at the Hospital of the University of Pennsylvania.
Studies show that patients from both groups are at risk for depression, anxiety and substance abuse disorder and may benefit from screening for mental distress. Self-worth and mental outlook are often interconnected with a patient’s efforts to cope with aspects of a rheumatic disease.
Results of one study revealed a majority of patients felt stigmatized by psoriasis and especially disliked that people stared at their skin changes.1 Additionally, depression worsened for people who felt stigmatized by their psoriasis in social situations.
Questionnaire responses indicated patients anticipated rejection and felt guilt and shame from the stigmatization. Greater awareness is needed to better inform the public that psoriasis is not contagious and is a disease like many other chronic conditions, study authors noted.1
People with joint pain from PsA may also socially isolate because when the condition flares, they often can’t participate in their usual activities, notes Dr. Ogdie. The loss of enjoyment from being active and the physical pain of aching joints can lead to, or deepen, depression and anxiety.
Dr. Ogdie
Researchers in Canada who examined the prevalence of anxiety and depression in psoriatic disease found the rate was significantly higher in patients who have PsA than those with psoriasis only, without PsA.2 The researchers estimated that about one in five patients with PsA have depression, and their rate of anxiety is even higher, according to their results and similar studies.
Disability, pain and fatigue were patient-reported factors that raised the likelihood of depression and anxiety in both patient cohorts. The researchers noted a high rate of depression and anxiety in patients with PsA may go under-recognized and undertreated.2
Some researchers theorize that inflammation in the brain, as well as inflammatory diseases that affect the brain, could be a cause of depression, says Dr. Ogdie. It is a somewhat popular premise, but establishing a clear causal link is difficult, and more research is needed, she says.
Comorbidities
Although ways to manage psoriasis and PsA exist, so far neither condition has a cure, which is a bitter pill for some newly diagnosed patients. For any patient, the long-term nature and stresses of a chronic disease can be an emotional hurdle on the path to good mental health.
“People may begin to think they are going to live with this disease for the rest of their lives, and it can be overwhelming and depressing,” says Dr. Ogdie. “Of course, that’s the part we try to reframe, but that’s a pretty natural feeling.”
Even though it’s quite common for people with psoriatic disease to have depression, patients often don’t realize the two can be related, says Dr. Ogdie. She explains to them that their PsA is less likely to get better if their active mental illness isn’t addressed.
“You would really want to get the depression treated so they can start to feel better overall and have a better quality of life,” says Dr. Ogdie.
Both depression and anxiety are well recognized comorbidities in patients with psoriasis and PsA. Further, struggles with mental illness are fairly common in patients with any chronic rheumatic disease, notes Elaine Husni, MD, MPH, vice chair, Department of Rheumatologic and Immunologic Diseases, Cleveland Clinic.
Numerous studies have examined probable connections between poor mental health and psoriatic disease. But it can be tricky to ascertain whether depression and anxiety is more prevalent in one rheumatic illness compared to others because disease severity varies among conditions and patients, according to Dr. Husni.
“When considering the incidence of mental health issues among [patients with various] rheumatic diseases, it is essential to conduct comparative studies between similar disease states of lupus or psoriatic arthritis or rheumatoid arthritis before drawing any conclusions,” notes Dr. Husni.
Dr. Husni
“Only through such rigorous comparisons can we gain a comprehensive understanding of the potential differences in mental health impact between these conditions,” advises Dr. Husni, highlighting the importance of avoiding assumptions without proper comparative analysis.
“I think most rheumatologists who deal with chronic conditions, whether it be psoriatic arthritis or lupus, are really mindful that chronic diseases can, at certain times, cause mental health issues,” says Dr. Husni.
Dr. Ogdie strongly suggests rheumatologists screen for depression and related symptoms at every patient visit. It could be the first step toward putting patients at ease so they are ready to talk about their mental health challenges in relation to their disease.
“I do that for two reasons,” says Dr. Ogdie, referring to regular depression-related screening. “One is to catch it, the other is to normalize it, and that this is just part of what I’m going to be asking about.
“Some of our therapies may affect depression as well, so we want to be careful that we’re identifying it,” she says. “It just kind of becomes part of the routine.”
A review of 56 studies of patients with psoriasis and PsA conducted in 2019 examined the patients’ perspectives and experiences to uncover gaps in patient-centered care.3 Suggestions to improve outcomes and satisfaction included support of a patient’s psychosocial needs.
“Sometimes it helps to actually manage the depression or mental health component as well as the physical health,” says Dr. Ogdie, “because if you’re depressed, you’re also probably not exercising very much or doing other things to take care of yourself.”
The quality of life for patients with PsA is adversely affected by the psychosocial burden of the disease, which can show up as sleep disorders, fatigue, depression, poor body image and reduced work productivity. Ideally, management of the disease involves a multidisciplinary medical team and algorithms that account for psychological and physical concerns of the patient, according to a study co-authored by Dr. Husni.4
Because rheumatologists are not typically trained in mental health, there’s a chance that depression, anxiety or other mental distress in a patient could be overlooked. Yet there are many reasons clinicians should pay close attention to a patient’s mental health status.
For example, research suggests the prevalence of suicide ideation is higher among people with psoriasis than among general medical patients.2 According to the National Psoriasis Foundation, ideas or thoughts of suicide have been reported in about 10% of people living with psoriasis.
In addition, patients with psoriasis or PsA may be more likely to stop therapy for their rheumatic conditions when they are depressed. Researchers note that both depression and anxiety can influence treatment adherence, health behaviors and perceived health.2
Another concern is that patients with psoriasis or PsA may turn to alcohol and drugs more than individuals without the disease. Mental health intervention could help patients avoid substance abuse or dependence that could adversely affect treatment of their rheumatic disease.
A German survey on addiction among patients with psoriasis found that nearly 24% were high-risk drinkers and 41% smoked regularly, both significantly higher than the general population, while 11% were at risk of drug abuse.5 About 50% of psoriatic patients in another study had evidence of mental health problems such as depression, anxiety and alcohol dependence.6
Patients with anxiety disorder may catastrophize when their psoriatic condition flares, notes Dr. Husni. They might drastically view the experience as the world ending or their disease getting much worse or else exaggerate their responses to pain or treatment. “It could affect sleep and sleep can impact their disease,” notes Dr. Husni.
Screening for Mental Health Concerns
Questionnaire
The Patient Health Questionnaire-9 (PHQ-9), which assesses degree of depression, is one tool Dr. Husni uses in her practice at point-of-care visits to spot mental health concerns among patients with PsA and psoriasis. The questionnaire is filled out just before the office visit and opens the door for a conversation between the rheumatologist and patient.
Mental illness has emerged from the shadows in recent years to become a popular topic in society, but some still stigmatize it. Address the topic with sensitivity, advises Dr. Husni, especially on a first visit or at diagnosis, so the patient doesn’t feel overwhelmed.
For example, “I’d say, ‘I see that you scored really low on this mood questionnaire,” Dr. Husni says. “A lot of my patients tell me they struggle with low mood—has this been the case for you?’”
Telling Signs
Certain clinical clues also suggest a patient is depressed or anxious. If a patient constantly looks down during an office visit and offers one-word answers or barely speaks at all, that might be a sign of mental distress, even if the questionnaire score is unremarkable, says Dr. Husni.
“Regardless of the screening, if we see that there is really poor eye contact and erratic behaviors or the patient is being very despondent, we would probably ask additional questions about [their] mood,” says Dr. Husni.
Possible questions include:
- Is your low mood affecting your health?
- Do you have feelings of helplessness?
- Is there someone in your family or social circle that you can talk to about how you are feeling?
Patient Trust
A trusting relationship between doctor and patient opens communication lines for talking about mental health in relation to management of a patient’s rheumatic condition. A patient’s first visit might not be the best time to launch into a big discussion on anxiety or depression, notes Dr. Husni. However, it is important to validate the patient’s feelings when they acknowledge them and then find a right time to address it.
“Build up trust,” advises Dr. Husni. “When you first meet a patient, it can take a little while to build rapport.”
Reach consensus with the patient to prioritize treatment for the psoriatic condition and, if necessary, incorporate a mental health discussion. That involves shared decision making between patient and doctor or perhaps a multidisciplinary medical team.
“Mental health has become one of those things that’s just as important as treating their skin and their joints symptoms,” says Dr. Husni.
Catherine Kolonko is a medical writer based in Oregon.
References
- Hrehorów E, Salomon J, Matusiak L, et al. Patients with psoriasis feel stigmatized. Acta Derm Venereol. 2012 Jan;92 (1):67–72.
- McDonough E, Ayearst R, Eder L, et al. Depression and anxiety in psoriatic disease: Prevalence and associated factors. J Rheumatol. 2014 May;41 (5):887–896.
- Sumpton D, Kelly A, Tunnicliffe DJ, et al. Patients’ perspectives and experience of psoriasis and psoriatic arthritis: A systematic review and thematic synthesis of qualitative studies. Arthritis Care Res (Hoboken). 2020 May;72 (5):711–722.
- Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351–360.
- Zink A, Herrmann M, Fischer T, et al. Addiction: An underestimated problem in psoriasis health care. J Eur Acad Dermatol Venereol. 2017 Aug;31(8):1308–1315.
- Sondermann W, Fiege O, Körber A, et al. Psychological burden of psoriatic patients in a German university hospital department. J Dermatol. 2021 Jun;48(6):794–806.
