Mood Disorders Common in Psoriatic Arthritis, But Poorly Recognized and Treated

Patients with psoriatic arthritis (PsA) are twice as likely to be depressed as those with psoriasis alone, and also more likely to show co-morbid depression and anxiety in greater numbers, according to researchers at the University of Toronto. However, they are even less likely than patients with psoriasis alone to receive direct treatment for the mood disorder.

The new evidence suggests that in PsA, the combination of joint and skin disease may be what increases patients’ risk for depression and anxiety.¹

The study of 306 men and women with PsA and 135 people with psoriasis also found that depression and anxiety were related to unemployment, and were (unsurprisingly) more common among those with greater disability, pain, and fatigue.

The analysis involved patients seen consecutively at PsA and dermatology clinics at the Toronto Western Hospital, most of them individuals in their mid-50s. They were assessed routinely for clinical and radiographic disease severity, answered questionnaires about health-related quality of life, and were rated for depression and anxiety using the Hospital Anxiety and Depression Scale (HADS).

More than a third of PsA patients (36.6%) reported anxiety, as did just one-fourth (24.4%) of patients with psoriasis alone. The depression rate for PsA was 22.2%, more than twice as high as the 9.6% rate among psoriasis patients without joint involvement.

These numbers are generally consistent with previous studies and with data from the National Psoriasis Foundation (NPF), which reports a 24% prevalence of depression in the disease.²

In this study women were more likely than men to report anxiety rather than depression, in contrast to previous studies of PsA and psoriasis which found higher rates of both among females.³

There were more men (61%) among the PsA patients than among those with psoriasis (49%), and they were more likely to be unemployed.   

Depression and anxiety were also more common among the unemployed (who were more likely to be males) whether they had PsA or psoriasis alone.

Earlier research has suggested that treatment with disease-modifying anti-rheumatic drugs (DMARDs) might help, particularly in light of the fact that (as these authors point out) proinflammatory cytokines have been associated with major depression, in this study neither the use of DMARDs nor non-steroidal anti-inflammatory drugs (NSAIDs) had any significant effect on the mood disorders.

There are, of course, medications for anxiety and depression, but in this study among those reporting depression only 25% of the PsA patients and 31% of those with psoriasis were currently taking antidepressants. In thsi population depression may be “both under-recognized and undertreated,” the authors comment. They went on to point out that this could have a feedback effect on the course of the rheumatic condition.

“Depression and anxiety are known to influence treatment adherence, health behaviors, and perceived health,” they observe. Indeed, “the factors most closely associated with higher rates of depression are those in which patients express the negative effects this disease [PsA] has on their quality of life.”

Although screening instruments can be helpful in spotting depression, the NPF notes in its 2008 guidelines, “simply asking questions about depressed mood and anhedonia appear[s] to detect a majority of depressed patients.”

In a 2012 study that found similar rates of depression (21.7%) in PsA, British researchers concluded that “attention to patients' anxiety and their concern about numerous bodily symptoms attributed to the illness may enable rheumatologists to identify and manage treatable aspects of HRQOL in PsA.”⁴

References:

1.  McDonough E, Ayearst R, Eder L, et al., Depression and Anxiety in Psoriatic Disease: Prevalence and Associated Factors.J Rheumatol. (2014) Apr 1. [Epub ahead of print]

2.  Kimball AB, Gladman D, Gelfand JM. et al., National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening. Journal of the American Academy of Dermatology (2008) 58:1031–1042.

3.  Khraishi M, MacDonald D, Rampakakis E, et al. Prevalence of patient-reported comorbidities in early and established psoriatic arthritis cohorts. Clin Rheumatol. (2011) 30:877-85.

4.  Kotsis K, Voulgari PV, Tsifetaki N, et al. Anxiety and depressive symptoms and illness perceptions in psoriatic arthritis and associations with physical health-related quality of life. Arthritis Care Res. (2012) 64:1593-1601.