COMMENTARY

The Connection Between Psoriasis and Depression: What You Need To Know

Richard G. Fried, MD, PhD

Disclosures

December 02, 2021

This transcript has been edited for clarity.

Hi. My name is Rick Fried. I am a dermatologist and clinical psychologist out of Yardley, Pennsylvania. I'm clinical director of Yardley Clinical Research Associates and Yardley Dermatology.

Today, I'm going to talk a little bit about depression and psoriasis, how they commingle, and what we can do to address our patients' issues and make the quality and quantity of their lives better.

It's an interesting thing. As our understanding of the pathophysiology of psoriasis continues to grow, the understanding of the pathophysiology of depression continues to grow as well. Certainly, we know that psoriasis is a cytokine-mediated inflammatory disorder, and we're more and more aware that depression is a cytokine-mediated inflammatory disorder.

The data are robust across decades that people who suffer with psoriasis are at higher risk for depression, higher risk for anxiety disorders, and higher risk for psychosocial impairments and functioning. We've come to understand that depression is more than we used to think it was. More in numbers, more in severity, and more to it than just "hey, living with psoriasis is tough."

Living with psoriasis is tough. It's more and more recognized that there are disorders of sensation with psoriasis that are awful, such as pruritis and other dysesthesias, including burning, pain, crawling, and biting. Living with psoriasis, as we know, is very difficult due to the demands of the disease, stigmatization, prejudice in the workplace, and difficulties with relationships.

We've also come to understand that the inflammatory cytokines that are involved in the production and sustaining of psoriasis lesions do not stay in the skin. It's now been shown that the cytokines cross the blood-brain barrier, and that they actually increase reuptake of neurotransmitters at the level of the synapse. Psoriasis sufferers are chemically depleted of norepinephrine, serotonin, and dopamine.

Let's return to depression. Now, the question is whether the depression that accompanies psoriasis is because of cytokine neurotransmitter depletion or because of living with the demands and the physical burden of the disease. The answer is both.

How do we know who of our patients are significantly burdened by depression? How do we know which of these patients need treatment and what the treatments are? First, we have the DSM-5 traditional signs of depression, including blunted affect, decreased energy, hypersomnolence, sadness, and social withdrawal.

I think a more pervasive type of depression we see in dermatologic practice is what I call subclinical depression. These are people who can appropriately smile at a party, laugh at a joke, and go through the motions of day and night. But you know what? There's a pervasive blah. Food doesn't taste as good, flowers don't smell as sweet, and sex doesn't feel as good — if they have any interest whatsoever. This is often attributed to distress, COVID-19, or age — I'm 46 or I'm 64.

This subclinical depression can lead to greater stress, the worsening of psoriasis, further social withdrawal — and around the vicious cycle goes. It's our obligation to be vigilant for depression in the form of subclinical depression or traditional DSM-5 depression. The question is, is it a good idea to treat depression? And whose job is it?

Every dermatologic visit should include the following: "Hey, Joe, how are you doing with your psoriasis?"

"Fine, doc. Same old, same old."

"Honestly, Joe, how tough is it to live with your psoriasis?"

If you hold eye contact for up to 5 seconds, often you'll see tears starting to well and they will talk, saying they hate it. It's wrecking this and that, and they've got it right there. Sometimes they don't even have an awareness of how much it's had an impact until you say, "Hey, are you still going out? Are you still going dancing? Are you still going bowling?"

Only 30 seconds of engagement and questions can convey a number of things. Number one, you give a damn. Number two, you understand the burden of disease. Number three, it's understood that depression accompanies psoriasis.

Then, move from there and say, “There has never been a better time to have psoriasis. The treatments we have today are better than they've ever been.” There is no such thing as an empty toolbox. Promise that you will stand by their side until you find the treatment that gets their psoriasis to the level they need it and want it to be.

We're offering hope, and, more than anything else, we're offering control. Psoriasis is enormously capricious. It comes and goes whenever it wants to come and go. When you put human beings together with a capricious disease, it can be enormously overwhelming. We sell control every day as dermatologists.

What kind of control? Number one, obviously, is legitimate therapies. We are making sure we're moving stepwise in an efficient manner until their psoriasis is sufficiently controlled and that they don't reach a critical mass before the damage from psoriasis — whether it's to their joints, their systemic organs, or their psyche — becomes irreparable.

That may mean moving them to better topicals, narrowband ultraviolet light B (UVB), phosphodiesterase-4 inhibitors or other biologics, or a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI). We now know that if you add an SSRI or SNRI, number one, they've been shown to decrease inflammation. Number two, they've been shown to enhance the response of psoriasis to traditional treatments.

What about mindfulness meditation? There are clear data that mindfulness meditation can decrease the amount of UVB necessary to clear psoriasis, can make biologics work better, and can make topicals work better.

Yoga, tai chi, and progressive muscle relaxation can be helpful. Cognitive-behavioral psychotherapy is enormously helpful for the concomitant treatment of psoriasis. What about other online avenues? Support groups are unquestionably helpful in the form of concrete ideas and concrete behaviors that our patients can do.

What about dermatologists and psychiatric medications? There is a hesitancy on the part of dermatologists to prescribe psychiatric medications unless it is doxepin, which has been anointed by some great governing force that said it's not really a psychiatric medication. We write psychiatric medications and we should be writing psychiatric medications.

We must be vigilant for critical mass of depression where the patient is at risk. Ask direct questions about and watch for signs of thoughts of suicide; signs of withdrawal to the point where they cannot function at work; and signs of high levels of impulse and concomitant substance abuse, whether alcohol, drugs, or otherwise.

Most of all, as I said, offer them empathy, support, and an appropriate referral. We, in our practice, talk about skin emotion specialists, which are psychologists and psychiatrists who have a special interest in skin diseases, including psoriasis, eczema, and rosacea, who have tools and techniques that can make the skin behave better.

If they say, "Do you think I have a psychological problem, doc?" Say, "No, I think your skin has a biologic problem that can be stressful, distressful, and could cause chemical changes in the brain that can lead to depression. To not address and treat that would be just awful and would leave you without appropriate treatment. I do want to offer you, in addition to our current regimen, medications that can help your skin behave better, help you feel better, and help the vibrancy and the breadth, warmth, and beauty of your life return."

One of the very important things about incorporating psychotropic medications into dermatologic regimens is the saying "start low, go slow." Often, we can do very well with very low doses of psychotropics, for example, sertraline at 20-50 mg or an SNRI, such as duloxetine, at 30 mg a day instead of at higher doses of 60 mg. Often, lower doses work quite nicely and, as with most medications, minimize intrusive side effects.

Again, this is Rick Fried, dermatologist and clinical psychologist, and clinical director of Yardley Clinical Research Associates and Yardley Dermatology Associates. Thanks so much for listening.

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