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Background: Despite some evidence that psoriatic arthritis (PsA) may increase psychological burden in psoriasis, the mental health of this subpopulation is under-investigated. Objectives: To investigate whether PsA is associated with higher depression and anxiety in moderate-to-severe psoriasis; explore whether pain mediates these associations; and estimate the prevalence of undiagnosed and untreated depression. Methods: Baseline data from British Association of Dermatologists Biologic and Immunomodulators Register (BADBIR) participants completing the Hospital Anxiety and Depression Scale (HADS) were analysed. Results: 707 patients (n = 540 with psoriasis only; n = 167 with PsA) were included. Depression prevalence was higher in patients with than without PsA, when a HADS-depression subscale cut-off ≥8 was used (33% vs. 23%, adjusted Odds Ratio [OR] (95% Confidence Intervals [CI]) = 1.64 (1.09-2.45)), but did not differ using the HADS cut-off ≥ 11. Anxiety prevalence was higher among PsA patients, regardless of HADS cut-off (cut-off ≥11: adjusted OR (95% CI) = 1.62 (1.07-2.45)). Pain fully mediated the effect of PsA on depression and anxiety in psoriasis. 53.6% of participants identified as depressed did not have a known psychiatric disorder; two thirds of depressed participants were not treated. Conclusions: PsA comorbidity in psoriasis is associated with higher anxiety; its association with depression appears to be robust when milder depressive syndromes are included, but less consistent for higher-threshold depression definitions. Depression remains unrecognized and untreated in over half of moderately-to-severe psoriasis patients. Routine depression and anxiety screening is recommended in psoriasis and PsA. PsA comorbidity may increase depression and anxiety in psoriasis through pain experience.
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Background: Psoriasis is a chronic systemic inflammatory skin disease, coexisting with depression in up to 25% of patients. Little is known about the drivers of comorbidity, including shared neurobiology and depression brain imaging patterns in patients. An immune-mediated crosstalk between the brain and skin has been hypothesized in psoriasis. With the aim of investigating brain structure and connectivity in psoriasis in relation to depression comorbidity, we conducted a brain imaging study including the largest psoriasis patient sample to date (to our knowledge) and the first to investigate the role of depression and systemic inflammation in brain measures. Effects of coexisting psoriatic arthritis (PsA), which represents joint involvement in psoriasis and a higher putative inflammatory state, were further explored. Methods: Brain magnetic resonance imaging (MRI) data of 1,048 UK Biobank participants were used (131 comorbid patients with psoriasis and depression, age-and sex-matched to: 131 non-depressed psoriasis patients; 393 depressed controls; and 393 non-depressed controls). Interaction effects of psoriasis and depression on volume, thickness and surface of a-priori defined regions of interest (ROIs), white matter tracts and 55x55 partial correlation resting-state connectivity matrices were investigated using general linear models. Linear regression was employed to test associations of brain measures with C-reactive protein (CRP) and neutrophil counts. Results: No differences in regional or global brain volumes or white matter integrity were found in patients with psoriasis compared to controls without psoriasis or PsA. Thickness in right precuneus was increased in psoriasis patients compared to controls, only when depression was present (ß = 0.26, 95% CI [Confidence Intervals] 0.08, 0.44; p = 0.02). In further analysis, psoriasis patients who had PsA exhibited fronto-occipital decoupling in resting-state connectivity compared to patients without joint involvement (ß = 0.39, 95% CI 0.13, 0.64; p = 0.005) and controls (ß = 0.49, 95% CI 0.25, 0.74; p < 0.001), which was unrelated to depression comorbidity. Precuneus thickness and fronto-occipital connectivity were not predicted by CRP or neutrophil counts. Precuneus thickening among depressed psoriasis patients showed a marginal correlation with recurrent lifetime suicidality. Conclusions: Our findings provide evidence for a combined effect of psoriasis and depression on the precuneus, which is not directly linked to systemic inflammation, and may relate to suicidality or altered somatosensory processing. The use of the UK Biobank may limit generalizability of results in populations with severe disease.
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Background: Illness perceptions in psoriasis have an impact on adherence and disability. Changes in dermatological healthcare provision during the Covid-19 pandemic and distress may have affected illness perceptions in psoriasis patients. Objectives: To test whether illness perceptions about psoriasis changed during the first year of the Covid-19 pandemic compared to pre-pandemic in a tertiary population with psoriasis and whether pandemic effects differed depending on depressive burden, given this population's high depression prevalence. Methods: In a cross-sectional survey of n = 188 tertiary patients with dermatologist-confirmed psoriasis recruited before and during the pandemic, eight illness perceptions domains were assessed using the Brief-Illness Perceptions Questionnaire (BIPQ). Presence of depression was assessed with the Hospital Anxiety and Depression Scale (HADS). Results: Beliefs about treatment control and patients' understanding of psoriasis were significantly worse in patients responding during the pandemic compared to before Covid-19. These differences were greater when depression was absent (treatment control: adjusted p < 0.001; coherence: adjusted p = 0.01). However, participants during the pandemic felt less emotionally affected (adjusted p = 0.02) and concerned (adjusted p = 0.007) about psoriasis, independently of depression. Conclusions: We found diverse pandemic effects on illness perception domains in psoriasis. Uncertainty and reduced healthcare access may drive poorer treatment and coherence beliefs during Covid-19. These beliefs can hinder patients' health-promoting behaviours and may explain the high pandemic non-adherence reported previously in psoriasis. Appropriate interventions are needed to establish positive long-term cognitions and improve psoriasis management, for example, using the PsoWell patient materials. Dermatology services should invest in engaging and educating patients regardless of concurrent psychological distress.
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BACKGROUND: Depression is overrepresented in psoriasis. However, it is not clear whether the presence of psoriatic arthritis (PsA) independently increases patients' depressive burden. Furthermore, current evidence regarding suicidality risk of psoriasis populations is conflicting, and the role of PsA in suicidality outcomes of psoriasis is unknown. OBJECTIVES: (i) To test whether PsA is associated with depression and lifetime suicidal ideation among patients with psoriasis; (ii) to capture different suicidal phenomena in these patients; and (iii) to investigate whether suicidality and depressive symptom severity are associated with clinical markers of psoriasis severity and chronicity. METHODS: A cross-sectional survey of tertiary patients (n = 219, aged 18-65 years) with dermatologist-confirmed chronic plaque psoriasis, of whom 84 had rheumatologist-confirmed PsA, was undertaken. The Hospital Anxiety and Depression Scale and Sheehan-Suicidality Tracking Scale were used to assess depression and lifetime suicidality, respectively. RESULTS: PsA presence was associated with depression in patients with psoriasis, independent of other physical comorbidities (adjusted odds ratio 2.92, 95% confidence interval 1.53-5.68). Furthermore, patients with PsA experienced significantly higher levels of anhedonia and anxiety, after controlling for psychiatric history. Of all participants, 48.8% reported lifetime suicidal ideation with or without intent, 21.3% reported suicidal planning, and 9.4% reported suicide attempts. Lifetime suicidality prevalence did not differ between patients with and without PsA. Depressive symptom severity and lifetime suicidality scores were not associated with objective measures of psoriasis severity or treatment group. CONCLUSIONS: These data suggest that joint involvement in psoriasis is associated with higher depressive burden. There is a need for routine depression screening among patients with psoriasis, particularly when PsA is present. Anhedonia appears to be a particularly relevant symptom in the depression phenotype of this population. We did not find a statistically significant association between PsA and suicidality. Nevertheless, suicidality rates in tertiary patients with psoriasis appear to be higher than those in the general population. Suicidality monitoring is recommended to help in reducing future psychiatric morbidity and mortality in patients with psoriasis.