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May 8, 2019

Exploring Mental Disorders in Patients With Skin Diseases

Author Affiliations
  • 1Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles
  • 2Associate Editor, JAMA Dermatology
JAMA Dermatol. 2019;155(6):660-661. doi:10.1001/jamadermatol.2019.0139

As dermatologists, we have long observed an association between skin diseases and mental disorders. Although some patients develop mental disorders as a result of having skin diseases, others have mental disorders that manifest themselves in skin diseases. With the availability of large population databases, we now have a greater understanding of the type and severity of mental disorders among patients. As clinicians, it is important to determine the effect skin diseases have on mental health, explore mechanistic rationales, and screen for mental disorders among high-risk patients.

In this issue of JAMA Dermatology, Leisner and colleagues1 and Bang and colleagues2 used population-based cohorts to examine mental disorders in patients with psoriasis. Specifically, Leisner and colleagues1 examined the association between psoriasis and subsequent development of mental disorders by using a population-based Danish registry. The authors found that, compared with those without psoriasis, patients with psoriasis had a 72% increased risk of developing depression. Using a Korean registry, Bang and colleagues2 found that the risk of having depressive episodes was twice as high in Korean patients with psoriasis compared with controls.2 These rates of depression in patients with psoriasis from Europe and Asia are similar to depression rates seen in the United States. In the United States, an estimated 17% of patients with psoriasis have depression, which is double the rate of depression in those without psoriasis.3

What about mental disorders other than depression? In the study by Leisner and colleagues,1 patients with psoriasis appeared to have a higher risk of developing bipolar disorder than matched controls. In addition, patients with psoriasis may also have an increased risk of developing a host of other mental disorders, such as vascular dementia, anxiety, and personality disorders. It is noteworthy that those who completed long-term education had a lower risk of developing mental disorders compared with those who completed short-term education.

Mental disorders in patients with psoriasis may predispose some to developing suicidal thoughts and practicing suicidal behaviors. Studies have shown that patients with psoriasis are 33% more likely to attempt suicide and 20% more likely to commit suicide than those without psoriasis.4 Those who are younger and have more severe psoriasis are at the greatest risk of committing suicide.

Is the development of depression and bipolar disorder simply a consequence of having psoriasis? Or are there mechanistic underpinnings that help explain the observed association between these mental disorders and psoriasis?

The mechanism underlying the development of mental disorders among those with psoriasis is not well understood. However, evidence suggests that enhanced activities in the Th17 pathway may play a role.5,6 For example, the level of interleukin 17 was significantly higher in activated T cells among those with anxiety or depression compared with controls.6 Thus, T cell functional dysregulation may contribute, at least in part, to the higher risk of mental disorders in patients with psoriasis.

Although we recognize the increased risk of mental disorders in patients with psoriasis, one clinically important question remains: Do therapies that treat psoriasis effectively also decrease signs and symptoms of mental disorders? Literature consistently shows that patients whose psoriasis is successfully treated experience reduced bouts of depression.7,8 Furthermore, successful treatment of psoriasis also leads to improved quality of life. Because the onset of mental disorders can occur as early as 2 or 3 months following the diagnosis of psoriasis,2 it is important to treat psoriasis adequately and promptly.

Finally, as clinicians, how can we identify patients at risk for developing mental disorders? In busy dermatology clinics, consider using a brief, validated tool to screen for depression. The Patient Health Questionnaire-2 is a validated 2-item screening tool for depression.9 It asks the following 2 questions: (1) “Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?” and (2) “Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?” The response choices for these 2 questions are 0 (“not at all”), 1 (“several days”), 2 (“more than half the days”), or 3 (“nearly every day”). A total score of 3 or more is considered a positive screen for a depressive disorder, with sensitivity of 94% and specificity of 75%. Patients who have a positive screening for a depressive disorder should be referred to a mental health professional for further evaluation.

In conclusion, mental disorders are increased in patients with skin diseases, including psoriasis. T cell dysregulation is thought to play a role in the development of mood disorders. Successful treatment of skin diseases has been associated with reduced depressive signs and symptoms. Thus, early initiation of appropriate treatment for skin diseases is important in decreasing mental health comorbidities. Even in our fast-paced clinics, screening for mental disorders in high-risk populations can be worthwhile.

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Article Information

Corresponding Author: April W. Armstrong, MD, MPH, Department of Dermatology, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90078 (armstrongpublication@gmail.com).

Published Online: May 8, 2019. doi:10.1001/jamadermatol.2019.0139

Conflict of Interest Disclosures: Dr Armstrong has served as a research investigator and/or consultant to AbbVie, Bristol-Myers Squibb, Dermavant, Dermira, Eli Lilly, Janssen, Kyowa Hakko Kirin, Leo Pharma, Modernizing Medicine, Novartis, Ortho Dermatologics, Pfizer, Regeneron, Sanofi Genzyme, Science 37, and UCB Biopharma, for which she reports receiving grants and personal fees.

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Bang  CH, Yoon  JW, Chun  JH,  et al.  Association of psoriasis with mental health disorders in South Korea [published online May 8, 2019].  JAMA Dermatol. doi:10.1001/jamadermatol.2019.0315.Google Scholar
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