MAUI, HAWAII – The cardiovascular comorbidity associated with psoriasis has drawn much attention, yet depression is arguably an even more important psoriatic comorbid condition.
"I think the most important comorbidity of psoriasis is depression. We all talk about heart disease, we talk about diabetes, but depression is something that we see every day in the office. It’s a big, massively important issue in our psoriasis patients," Dr. Kenneth B. Gordon said at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.
Moreover, depression also is the comorbidity in which dermatologists can clearly make the biggest difference. While there is great hope that effective treatment of psoriasis will reduce comorbid cardiovascular morbidity and mortality, that hasn’t yet been proved true. In contrast, there are persuasive clinical trials data demonstrating that effectively treating psoriasis markedly improves patients’ comorbid depression, according to Dr. Gordon, professor of dermatology at Northwestern University, Chicago.
For example, a clinical trial involving 1,230 psoriasis patients randomized to ustekinumab or placebo showed that at baseline 27% of subjects had clinically significant depression based upon the Hospital Anxiety and Depression Scale (HADS). After 12 weeks of therapy, the ustekinumab group showed a highly significant 29% decrease in mean HADS scores, compared with baseline. At the 12-week mark, 8.7% of placebo-treated controls had moderate depression as defined by a HADS score of 11-14, compared with 3.9% on ustekinumab. Severe depression, with a HADS score of 15-21, was present in 2.7% of controls and just 0.8% of patients on ustekinumab (J. Am. Acad. Dermatol. 2010;63:457-65).
"Maybe you don’t think of ustekinumab as a treatment for depression, but the size of the severely depressed group on ustekinumab markedly diminished over time. You’re taking people with clinically very significant depression and making it better," Dr. Gordon observed.
Similarly, a randomized trial in which 96 psoriasis patients received 40 mg of adalimumab or placebo every 2 weeks showed that patients with a 75% or greater decrease in baseline Psoriasis Area and Severity Index scores, or PASI-75 response, at 12 weeks averaged a 10.6-point reduction on the Zung Self-Rating Depression Scale. Nonresponders to the tumor necrosis factor inhibitor had a nonsignificant 1.4-point drop in Zung scores (J. Am. Acad. Dermatol. 2010;62:812-8).
This antidepressant effect of psoriasis treatment is not limited to the biologic agents, either, the dermatologist noted. He pointed to a recent study in which patients with refractory psoriasis were placed on the Goeckerman regimen involving UV phototherapy and coal tar. They received an average of 30 treatment sessions over 4-6 weeks. As their mean PASI scores fell from 27.1 to 6.9, their mean HADS depression scores dropped from 9.1 to 6.8 (Acta Derm. Venereol. 2011;91:447-51).
Based upon these and other data, Dr. Gordon proposed that the quality measures now being developed for psoriasis management ought to include identification of comorbid depression and demonstration of its improvement during psoriasis therapy.
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Dr. Gordon reported receiving research support and/or serving as a consultant to seven pharmaceutical companies but is not on any speakers bureaus.