Understanding the Impact of Depressive Symptoms in Patients with Psoriasis

Dr. Turck:
Welcome to DermConsult on ReachMD.  I’m Dr. Charles Turck, and joining me to discuss her recent study on disease severity based on depressive symptoms in patients with psoriasis is Dr. Neda Shahriari.  She’s a Board-Certified Dermatologist at Brigham and Women’s Hospital in Boston, Massachusetts, and also an Instructor of Dermatology at Harvard Medical School. 

Dr. Shahriari, thanks for being here today. 

Dr. Shahriari:
Thank you so much for having me.  I’m very excited to be talking about this really important topic and study.

Dr. Turck:
Well, to get us started, let’s dive into that study.  Why was this an important study to conduct?  And what did we know about the topic beforehand? 

Dr. Shahriari:
Great.  Absolutely.  So one of the important things with patients who have psoriasis is looking at them from more of a holistic approach, so it’s not just about evaluating our patients’ skin disease but thinking about what other issues can come about knowing that they have psoriasis.  So it’s very common for us to think about the relationship between psoriasis and psoriatic arthritis, so there’s a lot of literature pertaining to that.  But when it comes to the link between psoriasis and depression, there’s a little bit more lacking in the literature, so that was really the impetus of this particular study was to really be able to evaluate depressive symptoms in our psoriasis patients, and how as dermatologists we can really make a difference in this sphere for our patients. 

Dr. Turck:
And what else can you tell us about the objective of the study, and what you were looking to accomplish?

Dr. Shahriari:
Right.  So a couple of different things, actually.  Number one question is when are patients with psoriasis—depending on the degree of involvement of their skin—will that impact or will that give us any clue as to whether these patients will have depression or not?  So thinking about it, you may assume that, well, if there is more involvement of the skin, that that may indicate that this patient is more likely to have depression, so if we logically think about it is what would make sense.  And part of that comes from the thought process that, number one, we know that part of the reason that our psoriasis patients are experiencing depressive symptoms is there’s a psychosocial aspect of it, so the fact that they have this disease and it’s very much visible, so it has a great impact on them psychologically.  But there’s also a biologic mechanism as well.  So these patients who are getting the psoriasis just how they’re having inflammation in their skin, studies have actually shown that they are similarly getting some of those same inflammatory markers and cytokines involving the central nervous system that can lead to depression.

Dr. Turck:
So putting this together, it would make us think that, well, then if someone has a lot more psoriasis on their skin, does that then mean that they’re going to be at increased risk for depression? 

Dr. Shahriari:
So there’s actually some data in the literature, and it was mixed in this regard.  And our study looked at this as well, and what we found was that there was no particular link in terms of the amount of skin disease involved and the risk of depression, so it was actually pretty similar.  And so the reason that that is really important for us to make note of is as dermatologists, we’re not really going to be managing depressive symptoms, but if we can figure out little clues to help us distinguish which patient is at risk, it would be helpful.  And what I can say is, based on our study, looking at the skin alone is not going to be the way to go about finding these patients who are at risk because you can’t say that, “Oh, this patient has more skin disease, so therefore, they’re going to be at risk for depression.”  We’re going to have to look at other factors to help us.  And so one thing that was particularly helpful that we found in our study is that the patients’ subjective assessment of their just overall what we call patient-reported outcomes is actually a way to be able to determine that. 

So this was a registry that we were looking at.  When these patients are enrolled in this registry, they’re supposed to fill out some questionnaires about how they feel that their itch level is, what is their level of fatigue, so these very subjective questions, and what we found was that looking at that portion of the assessments can actually clue us into which patients are at risk for having depression, and therefore, we can help facilitate them getting the care that they need. 

Dr. Turck:
Now jumping back for a moment, could you share any other specifics about the study’s design and the patient populations studied? 

Dr. Shahriari:
Absolutely.  The Corrona Psoriasis Registry was established several years ago, and it derives from patients in Canada, as well as the United States, so there’s multiple sites across the two countries that contribute to the population enrolled in this registry.  And patients can be eligible to be part of this registry as long as they are on a systemic medicine, whether that’s a biologic or not a biologic, and they have to be above the age of 18 and have psoriasis.  So this is the patient population that we are enrolling in, in this particular registry, and then throughout time, these patients will have an initial visit.  They check in with us on an every six-month basis, and we’re collecting information about what their disease process is doing, and then what in terms of their subjective experience is happening with their disease process.  So it’s a great type of registry to help us better characterize our psoriasis patients, so it’s actually looking at real-world data of what these patients are going through.  So that’s the patient population. 

Dr. Turck:
For those just tuning in, you’re listening to DermConsult on ReachMD.  I’m Dr. Charles Turck, and I’m speaking with Dr. Neda Shahriari about the background of her study on disease severity based on depressive symptoms in patients with psoriasis.

Now jumping back to the study’s results, Dr. Shahriari, was there anything else you learned from the study about patients with and without a history of depression? 

Dr. Shahriari:
Yes.  So actually, one thing that was particularly interesting and unique was that we had data on which patients among this cohort was on antidepressants, like had a history of depression and was on antidepressants versus those who have depression and are not on antidepressants, and what was really interesting and we weren’t expecting this, but what we saw was that those patients who had the history of depression and were on antidepressants, were overall faring better in terms of both their disease characteristics, so meaning how much psoriasis involvement is there, how severe it is, but also their subjective type of assessments of how they feel that their disease process is going was also improved.  So in comparison to the two groups, we saw that those who were on antidepressants actually had better outcomes in general. 

So that was an interesting point because it pointed to a couple different things.  So number one, it raised the question of whether—is it that the antidepressants are having some biologic effect on these patients?  And the reason I say that is because part of what drives psoriasis is that it can get itchy, and you’re going to scratch in an area, and psoriasis basically has this phenomena that we call Koebnerization, so basically, you can start to develop psoriasis in areas that you’re scratching.  Antidepressants have been known to be able to help moderate some of this itch cycle, and so one thing that raised our attention was it possible that it’s mitigating some of that itching phenomena; therefore, it is helping to reduce this Koebnerization; therefore, reduce overall disease severity?  So that’s one mechanism that we postulated.  Could it be that just in general, like from a psychosocial aspect, that these patients are just feeling a lot better because their depression is addressed?  So there’s two different factors at play here, and it’s really hard for us to know which, or maybe both, are contributing to this.  But the bottom line is that it’s really exciting to see that knowing that if the patient has depression and they get on an antidepressant, that it can make both them feel better from a psychologic aspect but their disease better as well. 

So why that’s important?  It’s not that as dermatologists we’re going to be prescribing antidepressants, but it raises the point of how important it is that as someone who’s treating the skin disease, we need to work hard to screen these patients, and if we think that someone is raising suspicion for depression, that we should get them plugged in with our psychiatry colleagues who can then facilitate the patients getting an antidepressant, which can overall impact them psychologically, as well as in their disease process.  So that was one very interesting key point that we found, and we actually weren’t expecting to find, and it was very interesting.

Dr. Turck:
So just to recap, would you mind sharing any other highlights of your study’s results and the conclusions you came to? 

Dr. Shahriari:
So another thing that I would also highlight is that there were a lot of different aspects we looked at with this study, but we had seen in the literature that a couple of studies had pointed to the fact that if someone or if patients who have depression are put on a systemic treatment that somehow that may serve as a hindrance factor for them to improve, that the fact that they have depression may mean they may not respond as well to systemic treatment.  So as part of our study, we also looked at that factor just to see if this is something we’re seeing a signal in our patient population, but we actually disproved that, and we found that the presence of depression does not in any way hinder the patient’s response to systemic treatment, so that was another important good point to highlight from the study. 

Dr. Turck:
And finally, Dr. Shahriari, would you like to leave our audience with any key takeaways today, either about your study or even more globally about depression in patients with psoriasis? 

Dr. Shahriari:
Absolutely.  What I would want to highlight is that taking care of psoriasis patients, we need to think of it as more of a multidisciplinary approach.  And what I mean by that is, as dermatologists, we’re going to be taking care of the skin, but there’s a lot more that goes into psoriasis.  Our psoriasis patients are at an increased risk for psoriatic arthritis, so it’s important if we’re suspecting having that comorbidity that these patients should see a rheumatologist.  And similarly, depression is—these patients are at much increased risk for depression, not only depression but suicidal ideation as well—and all of that’s related to both the biologic mechanisms of the disease process and the psychosocial aspects of it.

So it’s hard because, as dermatologists, we don’t have a lot of time in the room with the patient.  We’re already trying to look at the skin, try to diagnose the disease process, and get the patients on the right treatment.  But one suggestion I have in terms of once we see a psoriasis patient is potentially doing a patient health questionnaire too, which is like a mental health assessment that’s only two questions, very quick, very easy, can risk stratify our psoriasis patients into whether we think that they have depressive symptoms or not.  And then if we think they are headed in that direction.  I think it’s important to get them plugged in with our psychiatry colleagues so that they can better address the mental health concerns as well because based on our study, addressing that impacts both how they feel, of course, which is a major point, but also can help the disease process as well.

Dr. Turck:
Those are great insights as we close our discussion today, and I want to thank my guest, Dr. Neda Shahriari, for joining me to discuss her study.  Dr. Shahriari, it was great having you on the program.

Dr. Shahriari:
Great.  Thank you so much for having me.

Dr. Turck:
For ReachMD, I’m Dr. Charles Turck.  To access this and other episodes in this series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge.  Thanks for listening.