Fortunately, although physicians in general are at a much greater risk of suicide than the general population, the dermatology specialty appears to have relatively low suicide rates.[i] Unfortunately, this cannot be said for the patients seen by dermatologists. Most chronic dermatoses have a strong correlation with mental health issues, in particular psoriasis. With respect to psoriasis, a correlation with increased mental health issues was published at least as early as 1946[ii], with the direct correlation to suicide risk coming some 20 years later.
From a practical perspective, many common anti-psoriatic drugs have potential mental health impacts. Higher-potency topical corticosteroids have been reported as having systemic absorption and subsequent mental state changes.[iii] Systemic corticosteroid therapy has been linked to increased suicidal ideation in multiple studies as well.
Although there seems to be little data specific to dermatological applications, in a study of rheumatoid arthritis patients, biological therapies had the highest suicide ideation rate of all systemic therapies studied: “The biological drugs group displayed the highest average score in BSI (25.73 ± 3.82), presenting serious suicidal ideation and thus drawing attention to the class of biological drugs”.[iv]
In addition to the possible mental health side effects of anti-psoriatic therapies, the possible effects of psychiatric medications on psoriasis and psoriasis therapies should be considered. Of particular note, lithium therapy has been linked to drug-induced psoriasis or exacerbation of existing psoriasis.[v]
Conversely, selective serotonin uptake inhibitors (SSRIs) have been linked to significant skin improvements in psoriatic patients. [vi] It should be noted that although many SSRIs have been linked to photosensitive reactions, this has most typically been found to be a UVA mediated reaction with much rarer reports of decreased UVB MED, allowing cautious narrowband UVB phototherapy use with SSRIs.[vii]
Overall, treatment of psoriasis patients requires an appreciation for mental health issues, and in particular the increased prevalence of suicide in psoriatic patients and the drugs that can exacerbate mental health issues that can lead to suicide.
[i] Hawton K, et al. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979–1995 Journal of Epidemiology & Community Health 2001;55:296-300.
[ii] Wittkower E: Psychological aspects of psoriasis. Lancet 1:566-569, 1946
[iii] Gupta, et al. Psoriasis and psychiatry: An update. General Hospital Psychiatry 9,3: , 157-166, 1987
[iv] Ribeiro, et al. Anxiety, depression and suicidal ideation in patients with rheumatoid arthritis in use of methotrexate, hydroxychloroquine, leflunomide and biological drugs. Comprehensive Psychiatry 54 (2013) 1185–1189
[v] Skoven I and Thormann J. Lithium compound treatment and psoriasis. Arch Dermatol. 1979 Oct;115(10):1185-7.
[vi] Thorslund, et al. Use of serotonin reuptake inhibitors in patients with psoriasis is associated with a decreased need for systemic psoriasis treatment: a population-based cohort study. J Intern Med. 2013 Sep;274(3):281-7
[vii] Doffoel‐Hantz, et al. Photosensitivity associated with selective serotonin reuptake inhibitors. Clin Exp Dermatol. 2009 Dec;34(8):e763-5.
