Dermatologic Disorders Increase Risk for Depression, Suicidal Behavior
Dermatologists need to recognize that asking about suicidal thoughts does not encourage patients to attempt suicide.
Dermatologic diseases such as acne, psoriasis, and atopic dermatitis can manifest as more than just skin lesions.1 Recent literature has uncovered common psychiatric comorbidities (depression, suicidal ideation, and body dysmorphic disorder) in up to 30% of dermatologic patients.1 The social isolation, itching, and sleep deprivation that accompany some skin lesions can leave patients feeling rejected and exhausted.1
The same inflammatory response that is associated with certain dermatologic illnesses such as psoriasis may also cause psychiatric manifestations.2 The association linking the proinflammatory cytokines interleukin 6 (IL-6), IL-1, IL-17, and tumor necrosis factor-alpha have been found in healthy patients with depression.2 Elevated cytokines may play a role in metabolizing serotonin.2
Who Is at Risk
Because of the high disease burden and its frequent comorbidities (obesity, hypertension, stroke, myocardial infarction, and metabolic syndrome), patients with psoriasis tend to have more psychiatric illness than others with dermatologic conditions.1
Dermatologic presentations with the potential for psychiatric illness include "sudden flares of any long-standing condition (hand dermatitis, psoriasis, atopic dermatitis) where the patient's level of concern and despondence is simply out of proportion to the degree of the flare," added Whitney A. High, MD, JD, MEng, associate professor of dermatology and pathology and director of dermatopathology at the University of Colorado School of Medicine in Denver.
A recent meta-analysis of more than 330,000 patients demonstrated that people with psoriasis vs people without psoriasis are more likely to experience suicidal ideation (pooled odds ratio [OR], 2.05; 95% CI, 1.54-2.74) and suicidal behaviors (includes attempted and completed suicides) with a pooled OR of 1.26 (95% CI, 1.13-1.40).2 The more severe the psoriasis and the younger the patient, the likelier they were to exhibit suicidality, largely because of social stigma and impaired quality of life.2 The most frequently used tools to assess suicidality were the Patient Health Questionnaire and the Beck Depression Inventory.2
Aside from suicidality, patients with psoriasis are 1.5 times more likely to have depression and 4 times more likely to use antidepressants than people who do not have psoriasis.2 Anxiety is also more prevalent in people with psoriasis than the general population.2
Where the lesions are on the body can also affect patients' moods.3 A study based on trends from the Norwegian Prescription Database found that compared with the general population, depression was more prevalent in patients with psoriasis (N=37,833) in intertriginous regions (OR, 1.32; 95% CI, 1.02-1.70), patients who required systemic medication (OR, 1.47; 95% CI, 1.00-2.17), and patients whose disease duration was >20 years (OR, 1.33; 95% CI, 1.09-1.64). However, the study did not find a general association between psoriasis and depression.3
Atopic dermatitis is also risk factor for psychiatric comorbidities, especially depression and suicidal ideation, because of the severe pruritus associated with eczema.1 The severity of itching is correlated directly with depression.1
Although more women attempt suicide, men are 3 times more likely to complete the action than women.1 Self-injury, however, is more common in women than in men.1
When to Screen
Knowing that certain dermatologic presentations have a higher risk for psychiatric illness should prompt clinicians to ask about overall well-being. "Several diseases may be associated with a lower quality of life, stress, depression, and/or anxiety. These include psoriasis, atopic dermatitis, and severe acne,"Lauren Ploch, MD, MEd, a board-certified dermatologist in private practice from Augusta, Georgia, told Dermatology Advisor.
Sometimes the lesions are a result of psychiatric disorders. "Several dermatologic conditions may coexist with a psychiatric condition, which often contributes to the dermatologic condition itself. Some examples of these include prurigo nodularis, delusions of parasitosis, and acne excoriée," explained Dr Ploch.
Although clinicians should note whether a patient is distressed about the dermatologic disorder, certain presentations warrant a more thorough assessment. Risk factors for suicide in dermatology patients include1:
- Patients with ≥1 psychiatric comorbidity (eg, major depressive disorder, body dysmorphic disorder, substance use disorder)
- Self-injury or self-induced dermatoses (eg, dermatitis artefacta, acne excoriée)
- Recent family death or traumatic episode
- Severe, chronic medical conditions (eg, psoriasis, hidradenitis suppurativa)
- Sleep deprivation, insomnia resulting from the dermatologic disorder or comorbidity
- Chronic facial scarring or lesions
- Social isolation resulting from the dermatologic disorder
- Use of dermatologic drugs that could increase risk for suicidal behaviors (eg, isotretinoin, tumor necrosis factor-alpha inhibitors, IL-17 inhibitors, apremilast)
- Patients with psychiatric disorders experiencing cutaneous adverse events (eg, patient with bipolar disorder reacting to erythema multiforme/Stevens-Johnson syndrome from lamotrigine)
What to Ask
Dermatologists need to recognize that asking about suicidal thoughts does not encourage patients to attempt suicide.1 Patients want to express their thoughts about how their dermatologic illness is affecting their lives.1
"We assess and document the mood and affect of every patient. High-risk patients, ie, those on certain medications, such as isotretinoin, are screened with specific questions about mood swings and depression symptoms," said Dr Ploch.
In the case of isotretinoin, clinicians need to counsel their patients before prescribing because of the warnings about the potential for depression, violent behavior, and suicidal ideation.4 "This medication has a controversial association with depression and suicidal and homicidal ideation, so it would be very wise and sound medicolegally to say you had done some basic screening and talked to the patient about local resources (emergency department, suicide hotline) before you started the medication," advised Dr High.
As part of a routine dermatologic examination, the simplified 2-question Patient Health Questionnaire can detect major depression with a 92% specificity and an 83% sensitivity.5 The self-administered questions, scored on a scale of 0 to 3 (with 3 being the cut point for psychiatric referral) include5,6:
- "Over the last 2 weeks, how often have you been bothered by any of the following problems?"
- "Little interest or pleasure in doing things
- "Feeling down, depressed, or hopeless"
"To [these 2 questions], I often add: 'have you had thoughts or plans to hurt yourself or hurt others?' " said Dr High.
As a clinician, it is important to understand that skin diseases can cause some patients to develop psychiatric comorbidities such as depression, body dysmorphic disorder, and suicidal ideation. By asking the right questions, dermatologists may be able to uncover psychiatric illnesses and refer patients to proper care.
- Gupta MA, Pur DR, Vujcic B, Gupta AK. Suicidal behaviors in the dermatology patient. Clin Dermatol. 2017;35(3):302-311.
- Singh S, Taylor C, Kornmehl H, Armstrong AW. Psoriasis and suicidality: a systematic review and meta-analysis. J Am Acad Dermatol. 2017;77(3):425-440.
- Modalsli EH, Åsvold BO, Snekvik I, Romundstad PR, Naldi L, Saunes M. The association between the clinical diversity of psoriasis and depressive symptoms: the HUNT Study, Norway [published online August 13, 2017]. J Eur Acad Dermatol Venereol. doi: 10.1111/jdv.14449
- Absorica [prescribing information]. Jacksonville, FL: Ranbaxy Laboratories, Inc.; 2012.
- Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284-1292.
- The Patient Health Questionnaire-2 (PHQ-2) – Overview. http://www.cqaimh.org/pdf/tool_phq2.pdf. Accessed September 20, 2017.