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Hartono SP, Chatrath S, Aktas ON, Kubala SA, Capozza K, Myles IA, Silverberg JI, Schwartz A. Interventions for anxiety and depression in patients with atopic dermatitis: a systematic review and meta-analysis. Sci Rep 2024; 14:8844. [PMID: 38632375 PMCID: PMC11024101 DOI: 10.1038/s41598-024-59162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease that is associated with anxiety and depression. Few studies have addressed interventions for symptoms of anxiety and depression in this population. To determine the efficacy of interventions for anxiety and depression in patients with AD. PubMed, MEDLINE, EMBASE, and PsycINFO were searched from inception to November 2023. English-language studies published in peer-reviewed journals evaluating the effect of interventions on anxiety and/or depression using validated assessment tools on patients with AD were included. Titles, abstracts, and articles were screened by at least two independent reviewers. Of 1410 references that resulted in the initial search, 17 studies were included. Fourteen of these studies are randomized controlled trials, while the other 3 studies are prospective controlled trials with pre and post-test designs. Data were extracted using a standardized extraction form, and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. To accommodate trials with multiple interventions (each compared to a control group), we conducted a mixed-effects meta-analysis with the trial as a random effect. Prespecified outcomes were changes in symptoms of anxiety and depression in patients with AD as evaluated using standardized assessment tools. Of the 17 studies included in this systematic review, 7 pharmacological intervention studies with 4723 participants examining 5 different medications were included in a meta-analysis. Of these studies, only 1 study evaluated medications prescribed to treat anxiety and/or depression; the rest evaluated medications prescribed to treat AD. Meta-analysis of all the pharmacological interventions resulted in significant improvement in anxiety, depression, and combined anxiety-depression scale scores (standardized mean difference [95% CI]: - 0.29 [- 0.49 to - 0.09], - 0.27 [- 0.45 to - 0.08], - 0.27 [- 0.45 to - 0.08]) respectively. The 10 non-pharmacological studies with 2058 participants showed general improvement in anxiety but not depression. A meta-analysis of the non-pharmacological interventions was not conducted due to variable approaches and limited data. Pharmacological interventions designed to improve AD were found to improve anxiety and depression in patients with moderate-severe disease. More comprehensive studies on non-pharmacological and pharmacological interventions that primarily target anxiety and depression are needed.
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Affiliation(s)
- Stella P Hartono
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, 10 Center Drive, Bethesda, MD, 20852, USA.
| | | | - Ozge N Aktas
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, 10 Center Drive, Bethesda, MD, 20852, USA
| | - Stephanie A Kubala
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, 10 Center Drive, Bethesda, MD, 20852, USA
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, CA, USA
| | - Ian A Myles
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jonathan I Silverberg
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Mitsiou E, Kyriakou A, Parlapani E, Trigoni A, Trakatelli M, Apalla Z, Sotiriadis D, Lazaridou E, Patsatsi A. Correlation of Specific Inflammatory Markers With the Occurrence of Depression in Patients With Psoriasis and Their Use as Biomarkers for the Diagnosis of Depression. Dermatol Pract Concept 2024; 14:dpc.1402a104. [PMID: 38810053 PMCID: PMC11135957 DOI: 10.5826/dpc.1402a104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 05/31/2024] Open
Abstract
INTRODUCTION Psoriasis is a systemic disease of the skin and nails associated with a wide range of comorbidities such as depression, psoriatic arthritis and metabolic syndrome. OBJECTIVES The study aimed to examine a potential association between inflammatory markers (C- reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) and depression in patients with psoriasis. METHODS A total of 80 individuals were enrolled in the study. Case participants included 28 patients diagnosed with Psoriasis (Beck Depression Inventory-II: :0-13) and 24 patients diagnosed with Psoriasis and Depression (Beck Depression Inventory-II:14-63). Twenty-eight (28) healthy participants comprised the control group.Psoriasis severity was evaluated by using Psoriasis Area and Severity Index, Physician Global Assessment, Body Surface Area and Dermatology Life Quality Index. Written approval was obtained for its use in this study: Cardiff University (09/2015). Other factors considered in the study were obesity using the Body Mass Index, the levels of stress using the Beck Anxiety Inventory, and the presence of insomnia using the Athens Insomnia Scale. Blood draws and inflammatory markers measurements were performed for all participants. RESULTS Both CRP and ESR levels were higher in the case group (ie Psoriasis and Depression and Psoriasis) compared to healthy controls. Furthermore, psoriatic patients with depression showed increased CRP and ESR levels compared to those of psoriatic patients without depression. CONCLUSIONS The evaluation of both CRP and ESR and their use to detect the presence of depression in patients with psoriasis can be an important tool for their holistic treatment of theirs.
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Affiliation(s)
- Eleni Mitsiou
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Aikaterini Kyriakou
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Eleni Parlapani
- 1st Department of Psychiatry, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Trigoni
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Myrto Trakatelli
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Zoe Apalla
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Dimitrios Sotiriadis
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Elizabeth Lazaridou
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Aikaterini Patsatsi
- 2nd Dermatology Department, Aristotle University School of Medicine, Papageorgiou Hospital, Thessaloniki, Greece
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Dadwal N, Amisha, Singh D, Singh A. Quality-by-Design Approach for Investigating the Efficacy of Tacrolimus and Hyaluronic Acid-Loaded Ethosomal Gel in Dermal Management of Psoriasis: In Vitro, Ex Vivo, and In Vivo Evaluation. AAPS PharmSciTech 2023; 24:220. [PMID: 37914839 DOI: 10.1208/s12249-023-02678-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/12/2023] [Indexed: 11/03/2023] Open
Abstract
Psoriasis is an auto-immune condition with high keratinocyte hyperproliferation due to lower p53 and p22 levels. Tacrolimus, an immune suppressor, is considered one of the most effective drugs in suppressing psoriasis. Systematic administration of tacrolimus often leads to challenging side effects, namely increased infection risk, renal toxicity, neurological symptoms such as tremors and headaches, gastrointestinal disturbances, hypertension, skin-related problems, etc. To address this, a nanocarrier-based formulation of tacrolimus along with inclusion of hyaluronic acid was developed. The optimization and formulation of ethosomes via the ethanol injection technique were done based on the Box-Behnken experimental design. The results revealed hyaluronic acid-based tacrolimus ethosomes (HA-TAC-ETH) had nanometric vesicle size (315.7 ± 2.2 nm), polydispersity index (PDI) (0.472 ± 0.07), and high entrapment efficiency (88.3 ± 2.52%). The findings of drug release and skin permeation showed sustained drug release with increased dermal flux and enhancement ratio. The effectiveness of HA-TAC-ETH was confirmed in an imiquimod (5%)-prompted psoriasis model. The skin irritation score and Psoriasis Area and Severity Index (PASI) score indicated that HA-TAC-ETH gel has validated a decline in the entire factors (erythema, edema, and thickness) in the imiquimod-induced psoriasis model in contrast with TAC-ETH gel and TAC ointment. The fabricated HA-TAC-ETH opt gel proved to be safe and effective in in vivo studies and could be employed to treat psoriasis further.
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Affiliation(s)
- Nikhil Dadwal
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, 142 001, India
| | - Amisha
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, 142 001, India
| | - Dilpreet Singh
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, 142 001, India
- University Institute of Pharmaceutical Sciences, Chandigarh University, Gharuan, 140413, Mohali, India
| | - Amrinder Singh
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, 142 001, India.
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India.
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Andersch-Björkman Y, Micu E, Seifert O, Lonne-Rahm SB, Gillstedt M, Osmancevic A. Effects of brodalumab on psoriasis and depressive symptoms in patients with insufficient response to TNF-α inhibitors. J Dermatol 2023; 50:1401-1414. [PMID: 37650150 DOI: 10.1111/1346-8138.16917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/09/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023]
Abstract
The objective of this study was to evaluate emotions of depression and anxiety in psoriatic patients that due to insufficient response to tumor necrosis factor-alpha inhibition (TNF-α), underwent a treatment switch from TNF-α to interleukin 17 inhibition using brodalumab. The Self-rated Montgomery-Asberg Depression Rating Scale and the Hospital Anxiety and Depression Scale were used to assess depression and anxiety. A total of 20 patients with psoriasis were enrolled in the study. They were monitored for a period of 3 months following the transition to brodalumab treatment. The results showed a significant improvement in both the Psoriasis Area and Severity Index as well as symptoms of depression; anxiety symptoms showed a reduction, though not statistically significant. Perhaps of more interest, the positive effects on depression and anxiety seem to be independent of the reduction in skin related psoriatic lesions. These findings highlight the importance of addressing depressive and anxiety symptoms, together with psoriasis severity and quality of life, when managing patients with psoriasis.
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Affiliation(s)
- Ylva Andersch-Björkman
- Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Dermatology and Venereology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emanuela Micu
- Department of Dermatology and Venereology in Östergötland, Vrinnevihospital, Norrköping, Sweden
| | - Oliver Seifert
- Division of Cell Biology, Department of Biomedical and Clinical Sciences, The Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Martin Gillstedt
- Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Dermatology and Venereology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Amra Osmancevic
- Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Dermatology and Venereology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Papa V, Li Pomi F, Borgia F, Genovese S, Pioggia G, Gangemi S. "Mens Sana in Cute Sana"-A State of the Art of Mutual Etiopathogenetic Influence and Relevant Pathophysiological Pathways between Skin and Mental Disorders: An Integrated Approach to Contemporary Psychopathological Scenarios. Cells 2023; 12:1828. [PMID: 37508493 PMCID: PMC10377895 DOI: 10.3390/cells12141828] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
The negative socioeconomic impact of mental health disorders and skin diseases has increased in part due to the conflict between Russia and Ukraine, which has been a fertile ground for the emergence of psychopathologies. It is firmly established that there is a direct thread of etiopathogenetic communication between skin diseases and neuropsychiatric disorders, and the literature has tried to reveal the pathophysiological mechanisms governing such bidirectionality. This paper discusses this complex network of molecular pathways that are targeted by conventional and biological pharmacological agents that appear to impact two pathological spheres that previously seemed to have little connection. This molecular discussion is supplemented with a literature review, from a clinical viewpoint, regarding skin-brain etiopathogenetic bidirectionality. We focus on post-traumatic stress disorder (PTSD), which can be considered for all intents and purposes a systemic inflammatory disease that also affects the skin. A brief overview is also provided on the diagnostic-therapeutic and follow-up potential of oxidative and inflammatory markers potentially involved in the pathophysiological mechanisms treated. The aim is to clarify how these mechanisms may be useful in defining different stress-coping strategies and thus individual phenotypes of stress sensitivity/resistance in order to promote personalized medicine in the field of psychodermatology.
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Affiliation(s)
- Vincenzo Papa
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (V.P.); (S.G.)
| | - Federica Li Pomi
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98122 Messina, Italy;
| | - Francesco Borgia
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98122 Messina, Italy;
| | - Sara Genovese
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy; (S.G.); (G.P.)
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy; (S.G.); (G.P.)
| | - Sebastiano Gangemi
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (V.P.); (S.G.)
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Queiro R, Loredo M, Braña I, Pardo E, Alonso S, Alperi M. Managing psoriatic arthritis in different clinical scenarios. Expert Rev Clin Immunol 2023; 19:1469-1484. [PMID: 37589128 DOI: 10.1080/1744666x.2023.2249235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Psoriatic arthritis (PsA) is a chronic, immune-mediated disease characterized by synovio-entheseal inflammation. It is estimated to affect around 30% of patients with psoriasis and significantly reduces patients' physical function and quality of life. There is a growing number of treatment options for PsA, but due to the heterogeneous clinical features of the disease and prevalence of comorbidities, managing PsA can be challenging. AREAS COVERED In this article, we review current understanding of the disease and available pharmacological options. Based on published treatment guidelines, emerging evidence and clinical experience, we provide our expert opinion on treatment strategies, taking into consideration the predominant disease domain and the presence of comorbidities, which can impact treatment decisions and clinical outcomes. EXPERT OPINION Biological and targeted synthetic disease-modifying agents are dramatically improving the lives of patients with PsA. Biosimilar TNF inhibitors offer a particularly versatile and cost-effective option, whilst newer biologics and targeted synthetic molecules that can be used to treat most domains of psoriatic disease are an attractive alternative to TNF inhibitors. Despite a lack of consensus on treatment sequencing and tapering, it is important that PsA patients, especially those with comorbidities, are looked after by a multidisciplinary team to optimize their care.
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Affiliation(s)
- Rubén Queiro
- Rheumatology & ISPA Translational Immunology Division, Central University Hospital of Asturias, Oviedo, Spain
- Department of Medicine, Oviedo University School of Medicine, Oviedo, Spain
| | - Marta Loredo
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Ignacio Braña
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Estefanía Pardo
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Sara Alonso
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
| | - Mercedes Alperi
- Rheumatology Division, Central University Hospital of Asturias, Oviedo, Spain
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Boye KS, Stewart KD, Matza LS. Development of a Patient-Reported Outcome (PRO) Measure to Assess Emotional Impact of Treatment for Type 2 Diabetes. Diabetes Ther 2023:10.1007/s13300-023-01426-0. [PMID: 37351820 PMCID: PMC10363102 DOI: 10.1007/s13300-023-01426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/15/2023] [Indexed: 06/24/2023] Open
Abstract
INTRODUCTION Patients receiving treatment for type 2 diabetes (T2D) may experience an emotional impact associated with treatment-related changes. A patient-reported outcome (PRO) measure assessing both positive and negative emotional impact of medication treatment for T2D is needed to better understand the patient experience of treatment. The purpose of this qualitative study was to explore the emotional impact of treatment for T2D and support the development of a questionnaire to assess the emotional impact of treatment for T2D. METHODS Exit interviews were conducted with patients with T2D participating in the SURPASS-2 and SURPASS-3 trials for tirzepatide. The exit interviews included a concept elicitation section focusing on the emotional impact of their study treatment. Results were used to develop two questionnaires that were evaluated in cognitive interviews with patients with T2D. RESULTS The concept elicitation interviews included 28 patients (mean age 57.6 years; 64.3% female). Most patients reported positive changes in emotions associated with tirzepatide, including increased confidence (n = 23; 82.1%), hope (n = 23; 82.1%), self-esteem (n = 23; 82.1%), relief (n = 22; 78.6%), optimism (n = 21; 75.0%), sense of control (n = 21; 75.0%), happiness (n = 15; 53.6%), and motivation (n = 15; 53.6%), as well as reduced worry/anxiety (n = 19; 67.9%). Negative emotional impact was less commonly reported but included frustration (n = 2; 7.1%), worry/anxiety (n = 1; 3.6%), fear (n = 1; 3.6%), and feeling depressed (n = 1; 3.6%). Two new PROs, the Emotional Impact of Diabetes Treatment Questionnaires (EIDTQ, status and comparison versions), were developed based on these finding. The status version assesses the emotional impact of current treatment, while the comparison version allows for comparison of the current treatment to a previous treatment. The questionnaires were refined on the basis of cognitive interviews with 20 additional patients (mean age 58.3 years; 60.0% female), and results suggest that the final instruments were clear, comprehensible, and relevant to patients. CONCLUSION The EIDTQ-Status and Comparison measures can be used as a supplement to clinical outcomes, such as hemoglobin A1c (HbA1c) and body weight, to provide a broader picture of the patient's emotional experience with medication treatment for T2D.
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Affiliation(s)
| | - Katie D Stewart
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD, 20814, USA
| | - Louis S Matza
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD, 20814, USA.
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8
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Panagiotopoulos A, Fragoulis GE. Comorbidities in Psoriatic Arthritis: A Narrative Review. Clin Ther 2023; 45:177-189. [PMID: 36737317 DOI: 10.1016/j.clinthera.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/03/2023] [Accepted: 01/12/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE Psoriatic arthritis (PsA) is a common type of inflammatory arthritis. Patients with PsA present with certain extra-articular manifestations and comorbidities (often collectively called psoriatic disease). The purpose of the present review was to highlight the main comorbidities in the setting of PsA. METHODS A narrative review was performed using data from articles found in a search of PubMed and Scopus using the terms psoriatic arthritis and comorbidities. FINDINGS Cardiovascular disease (CVD), as well as metabolic and mental health disorders, are the most common comorbidities in patients with PsA. In most cases, underlying inflammation seems to be involved in the increased risk for CVD in PsA, while a bidirectional relationship seems to operate between mental health disorders and psoriatic disease. The treatment of patients with PsA, especially with biologic disease-modifying antirheumatic drugs, has been shown to lead to favorable outcomes regarding the CVD risk. However, it is debatable whether specific drug classes are more effective than others or should be avoided in patients with CVD risk factors. Comorbidity of mental health disorders is even more complex, given the difficulties in measuring and reporting these comorbidities in clinical trials and in clinical practice. IMPLICATIONS Future studies are needed for a better understanding of the pathogenic mechanisms of, and the development of better protocols for the identification and treatment of patients with, comorbidities in patients with PsA. The education of clinicians, health care professionals in rheumatology, and patients could be useful in achieving this goal.
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Affiliation(s)
- Alexandros Panagiotopoulos
- Joint Academic Rheumatology Program, First Department of Propedeutic Internal Medicine, University of Athens, Athens, Greece
| | - George E Fragoulis
- Joint Academic Rheumatology Program, First Department of Propedeutic Internal Medicine, University of Athens, Athens, Greece; Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom.
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Adesanya EI, Matthewman J, Schonmann Y, Hayes JF, Henderson A, Mathur R, Mulick AR, Smith CH, Langan SM, Mansfield KE. Factors associated with depression, anxiety and severe mental illness among adults with atopic eczema or psoriasis: a systematic review and meta-analysis. Br J Dermatol 2022; 188:460-470. [PMID: 36745557 DOI: 10.1093/bjd/ljac132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Evidence suggests an association between atopic eczema (AE) or psoriasis and mental illness; however, the factors associated with mental illness are unclear. OBJECTIVES To synthesize and evaluate all available evidence on factors associated with depression, anxiety and severe mental illness (SMI) among adults with AE or psoriasis. METHODS We searched electronic databases, grey literature databases and clinical trial registries from inception to February 2022 for studies of adults with AE or psoriasis. Eligible studies included randomized controlled trials (RCTs), cohort, cross-sectional or case-control studies where effect estimates of factors associated with depression, anxiety or SMI were reported. We did not apply language or geographical restrictions. We assessed risk of bias using the Quality in Prognosis Studies tool. We synthesized results narratively, and if at least two studies were sufficiently homogeneous, we pooled effect estimates in a random effects meta-analysis. RESULTS We included 21 studies (11 observational, 10 RCTs). No observational studies in AE fulfilled our eligibility criteria. Observational studies in people with psoriasis mostly investigated factors associated with depression or anxiety - one cross-sectional study investigated factors associated with schizophrenia. Pooled effect estimates suggest that female sex and psoriatic arthritis were associated with depression [female sex: odds ratio (OR) 1.62, 95% confidence interval (CI) 1.09-2.40, 95% prediction intervals (PIs) 0.62-4.23, I2 = 24.90%, τ2 = 0.05; psoriatic arthritis: OR 2.26, 95% CI 1.56-3.25, 95% PI 0.21-24.23, I2 = 0.00%, τ2 = 0.00] and anxiety (female sex: OR 2.59, 95% CI 1.32-5.07, 95% PI 0.00-3956.27, I2 = 61.90%, τ2 = 0.22; psoriatic arthritis: OR 1.98, 95% CI 1.33-2.94, I2 = 0.00%, τ2 = 0.00). Moderate/severe psoriasis was associated with anxiety (OR 1.14, 95% CI 1.05-1.25, I2 0.00%, τ2 = 0.00), but not depression. Evidence from RCTs suggested that adults with AE or psoriasis given placebo had higher depression and anxiety scores compared with comparators given targeted treatment (e.g. biologic agents). CONCLUSIONS Our review highlights limited existing research on factors associated with depression, anxiety and SMI in adults with AE or psoriasis. Observational evidence on factors associated with depression or anxiety in people with psoriasis was conflicting or from single studies, but some identified factors were consistent with those in the general population. Evidence on factors associated with SMIs in people with AE or psoriasis was particularly limited. Evidence from RCTs suggested that AE and psoriasis treated with placebo was associated with higher depression and anxiety scores compared with skin disease treated with targeted therapy; however, follow-up was limited. Therefore, long-term effects on mental health are unclear.
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Affiliation(s)
- Elizabeth I Adesanya
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Julian Matthewman
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Yochai Schonmann
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Department of Quality Measurements and Research, Clalit Health Services, Tel Aviv, Israel
| | - Joseph F Hayes
- Division of Psychiatry, University College London, London, UK
| | - Alasdair Henderson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy R Mulick
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine H Smith
- St John's Institute of Dermatology, Guys and St Thomas' Foundation Trust and King's College London, London, UK
| | - Sinéad M Langan
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,Health Data Research UK, London, UK
| | - Kathryn E Mansfield
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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da Silva N, Augustin M, Hilbring C, Braren-von Stülpnagel CC, Sommer R. Psychological (co)morbidity in patients with psoriasis: the impact of pruritus and anogenital involvement on symptoms of depression and anxiety and on body dysmorphic concerns - a cross-sectional study. BMJ Open 2022; 12:e055477. [PMID: 36153012 PMCID: PMC9511542 DOI: 10.1136/bmjopen-2021-055477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES While stress plays a paramount role on the onset/exacerbation of psoriasis, via overactivation of the hypothalamic-pituitary-adrenal axis and increased release of pro-inflammatory cytokines, cutaneous inflammatory response induces, in turn, anxiety/depression symptoms, via body disfigurement and stigmatisation. The intensity of pruritus and anogenital involvement are additional risk factors for psychological comorbidity.Aims were to (1) examine the effects of intensity of pruritus and anogenital psoriasis on disease burden and psychological comorbidity and (2) identify the variables associated with the presence of clinically significant depression, anxiety, and dysmorphic concerns. DESIGN Cross-sectional study. SETTING Conducted at the University Medical Center Hamburg-Eppendorf (UKE). PARTICIPANTS 107 patients with psoriasis (mean age = 46.3, SD = 14.6 years; 53.3% male): 64 with none/mild pruritus; 43 with moderate/severe pruritus; 31 with anogenital psoriasis; 76 not affected in the anogenital area. PRIMARY/SECONDARY OUTCOMES MEASURES Disease severity was assessed with Psoriasis Area and Severity Index and intensity of pruritus was rated by patients. Patient-reported outcomes included the Dermatology Life Quality Index, ItchyQoL, Patient Benefit Index, Perceived Stigmatisation Questionnaire, and Relationship and Sexuality Scale. Psychological morbidity was assessed with the Patient Health Questionnaire, Generalised Anxiety Disorder, and Dysmorphic Concern Questionnaire. RESULTS Patients with moderate/severe pruritus reported more quality of life impairments, depression, anxiety and dysmorphic concerns, and less treatment benefits than those with none/mild pruritus. Moderate/severe pruritus had a deleterious effect on depression and stigmatisation for patients without anogenital involvement. Less patient benefits were associated with a higher likelihood of clinically significant depression/anxiety. CONCLUSION Pruritus induces significant burden and psychological morbidity, particularly for patients without anogenital involvement. However, coping strategies used by patients with anogenital psoriasis might be dysfunctional for overall psychosocial adaptation. Patient-centred healthcare might be the best way to prevent psychological comorbidity. ETHICS APPROVAL Ethics Committee of the Medical Association of Hamburg (process number PV6083, 28 May 2019).
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Affiliation(s)
- Neuza da Silva
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Matthias Augustin
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Caroline Hilbring
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Catharina C Braren-von Stülpnagel
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Rachel Sommer
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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11
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Tabra SA, Abd Elghany SE, Amer RA, Fouda MH, Abu-Zaid MH. Serum interleukin-23 levels: relation to depression, anxiety, and disease activity in psoriatic arthritis patients. Clin Rheumatol 2022; 41:3391-3399. [PMID: 35861930 PMCID: PMC9301620 DOI: 10.1007/s10067-022-06300-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022]
Abstract
Objectives Assessment of serum levels of IL-23 in PsA patients and its correlation with depression, anxiety, and disease activity. Methods Eighty psoriatic arthritis (PsA) patients and eighty healthy volunteers matched for age and gender were included in this observational case–control study. All participants suspected to detailed history, clinical assessment, PsA activity using Disease Activity Index for Psoriatic Arthritis (DAPSA) score, the severity and extent of psoriasis was assessed by the Psoriasis Area and Severity Index (PASI), and ultrasonographic assessments of the entheses were examined according to the Madrid Sonographic Enthesitis Index (MASEI). Depression and anxiety were assessed by Hospital Anxiety and Depression Scale (HADS). Serum IL-23 was measured and correlated with disease activity, depression, and anxiety. Results There was no significant difference between patients and controls regarding demographic data. Thirty-six PsA patients (45%) had anxiety and 28 patients (35%) had depression, while in the control group, 16 persons (20%) had anxiety and 12 (15%) had depression, with significant differences between the 2 groups (p < 0.0001). There were significant differences in HADS anxiety and depression scores between patients and controls with significant positive correlations between HADS depression, anxiety scores and IL-23, DAPSA, PASI, and MASEI scores (p < 0.05). IL-23 was positively correlated with DAPSA, PASI, and HADS scores; we observed that interleukin 23, higher DAPSA, and PASI were independently associated with depression and anxiety. Conclusion Serum interleukin-23 levels were elevated in PsA patients and were found to be correlated with depression, anxiety, and disease activity.
Key Points • Psoriatic arthritis is a multidimensional disorder with psychiatric drawbacks. • Interleukin-23 is a proinflammatory cytokines that was correlated with depression and anxiety in PsA patients. • Interleukin-23 was correlated with disease activity in PsA. • Depression and anxiety were positively correlated with disease activity in PsA. |
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Affiliation(s)
- Samar Abdalhamed Tabra
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Reham A Amer
- Department of Neuropsychiatry, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed H Fouda
- Department of Clinical Pathology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohammed Hassan Abu-Zaid
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Tanta University, Tanta, Egypt.
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12
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Hughes O, Hunter R. The Importance of Exploring the Role of Anger in People With Psoriasis. JMIR DERMATOLOGY 2022; 5:e33920. [PMID: 37632869 PMCID: PMC10334900 DOI: 10.2196/33920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/13/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Olivia Hughes
- School of Psychology, Cardiff University, Cardiff, United Kingdom
| | - Rachael Hunter
- Department of Psychology, Swansea University, Swansea, United Kingdom
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13
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Blackstone B, Patel R, Bewley A. Assessing and Improving Psychological Well-Being in Psoriasis: Considerations for the Clinician. Psoriasis (Auckl) 2022; 12:25-33. [PMID: 35371967 PMCID: PMC8965012 DOI: 10.2147/ptt.s328447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/02/2022] [Indexed: 11/27/2022] Open
Abstract
Psoriasis is a common chronic, systemic inflammatory disease, affecting approximately 2% of the population worldwide. Psoriasis is associated with profound psychosocial comorbidity with a burden that extends well beyond the physical signs and symptoms. Psychosocial comorbidities strongly associated with psoriasis include anxiety and depression, suicidal ideation, and substance misuse. There is a substantial unmet need for access to psychological support for people with skin disease in the UK. Recent reports found that while up to 98% of patients felt that their skin disease had affected their emotional or psychological well-being, only 18% sought help. This care gap is largely due to a lack of awareness about the limited available services alongside poor recognition, diagnosis, and triaging. Addressing psychosocial support needs starts with early identification, which can be complex and challenging. Once patients who need further support are identified, outcomes can be improved through prompt and effective treatment of inflammation, cognitive behavioural therapy, meditation and mindfulness-based therapy (including motivational interviewing), and to some extent psychotropic medication. Finally, resources for mental health support are notoriously limited, with dire consequences for patients. It is imperative that a proportion of the new funding promised for mental health services is bookmarked for dermatology patients and adequate provision of multidisciplinary psychodermatology teams to best serve the needs of this population. Ultimately, psoriasis is a complex condition with multifactorial psychological and biological drivers. Psoriasis is associated with high levels of distress, which is often under-recognized. Fully addressing this condition requires a holistic approach to the physical and psychosocial aspects to maximise adherence, efficacy, and optimise patient quality of life.
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Affiliation(s)
- Brittany Blackstone
- Bart’s Health NHS Foundation Trust, London, UK
- Correspondence: Brittany Blackstone, Department of General Internal Medicine, The Royal London Hospital, Whitechapel Road, London, E1 1FR, UK, Email ; Radhika Patel, Bart's Health NHS Foundation Trust, London, UK, Email
| | - Radhika Patel
- Bart’s Health NHS Foundation Trust, London, UK
- Correspondence: Brittany Blackstone, Department of General Internal Medicine, The Royal London Hospital, Whitechapel Road, London, E1 1FR, UK, Email ; Radhika Patel, Bart's Health NHS Foundation Trust, London, UK, Email
| | - Anthony Bewley
- Barts Health NHS Trust, Queen Mary University London, London, UK
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Lee TL, Tsai TF. Non-immune functions of inflammatory cytokines targeted by anti-psoriatic biologics: a review. Inflamm Res 2022; 71:157-168. [PMID: 34981130 DOI: 10.1007/s00011-021-01528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Psoriasis is an inflammatory disease characterized by skin thickening with silvery white desquamation due to dysregulated inflammatory pathways and elevated levels of inflammatory cytokines. Biologic agents targeting these inflammatory cytokines have brought about significant improvement in clearing psoriatic lesions in patients with moderate-to-severe psoriasis. Moreover, biologics exert both beneficial and detrimental effects on comorbidities in psoriasis, which include increased risk of cardiovascular events, metabolic syndrome, among other conditions. However, non-immune functions of cytokines targeted by biologics, and, hence, the potential risks and benefits of biologics for psoriasis to different organs/systems and comorbidities, have not been well elucidated. RESULTS This review summarizes current understanding of the pathogenesis of psoriasis-related comorbidities and emerging discoveries of roles of cytokines targeted in psoriasis treatment, including tumor necrosis factor α and interleukins 12, 23, and 17, aiming to complete the safety profile of each biologics and provide therapeutic implications on psoriasis-related comorbidities, and on diseases involving other organs or systems.
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Affiliation(s)
- Tung-Lin Lee
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, 7 Chung-Shan S. Rd., Taipei, 100, Taiwan.
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15
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Al-Janabi A, Yiu ZZN. Biologics in Psoriasis: Updated Perspectives on Long-Term Safety and Risk Management. Psoriasis (Auckl) 2022; 12:1-14. [PMID: 35024352 PMCID: PMC8747772 DOI: 10.2147/ptt.s328575] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/23/2021] [Indexed: 12/12/2022] Open
Abstract
Biologics targeting Th1/Th17 cytokines have revolutionised psoriasis treatment. In addition to treatment effectiveness, it is important to define and understand the long-term risks of biologic therapy in order to guide therapy selection and minimise these risks for patients where possible. This review article summarises available evidence from trial data, observational studies and pharmacovigilance registries to explore key long-term risks of biologic treatment, and how these risks might be managed in clinical practice.
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Affiliation(s)
- A Al-Janabi
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- The Dermatology Centre, Salford Royal NHS Foundation Trust, Manchester NIHR Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester, M6 8HD, UK
| | - Z Z N Yiu
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- The Dermatology Centre, Salford Royal NHS Foundation Trust, Manchester NIHR Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester, M6 8HD, UK
- Correspondence: ZZN Yiu Dermatology Centre, Salford Royal Hospital, Stott Lane, Manchester, M6 8HD, UK Email
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16
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Fabrazzo M, Cipolla S, Signoriello S, Camerlengo A, Calabrese G, Giordano GM, Argenziano G, Galderisi S. A systematic review on shared biological mechanisms of depression and anxiety in comorbidity with psoriasis, atopic dermatitis, and hidradenitis suppurativa. Eur Psychiatry 2021; 64:e71. [PMID: 34819201 PMCID: PMC8668448 DOI: 10.1192/j.eurpsy.2021.2249] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mental disorders in comorbidity with chronic skin diseases may worsen disease outcome and patients' quality of life. We hypothesized the comorbidity of depression, anxiety syndromes, or symptoms as attributable to biological mechanisms that the combined diseases share. METHODS We conducted a systematic review based on the Preferred Reporting Items for Systematic Review and Meta-Analysis statement searching into PubMed, PsycInfo, and Scopus databases. We examined the literature regarding the comorbidity of psoriasis (Ps), atopic dermatitis (AD), or hidradenitis suppurativa with depression and/or anxiety in adults ≥18 years and the hypothetical shared underlying biological mechanisms. RESULTS Sixteen studies were analyzed, mostly regarding Ps and AD. Brain-derived neurotrophic factor/tropomyosin receptor kinase B signaling and nuclear factor kappa-light-chain-enhancer of activated B cells/p38 mitogen-activated protein kinase pathways arose as shared mechanisms in Ps animal models with depression- and/or anxiety-like behaviors. Activated microglia and neuroinflammatory responses emerged in AD depressive models. As to genetic studies, atopic-dermatitis patients with comorbid anxiety traits carried the short variant of serotonin transporter and a polymorphism of the human translocator protein gene. A GA genotype of catechol-O-methyltransferase gene was instead associated with Ps. Reduced natural killer cell activity, IL-4, serotonin serum levels, and increased plasma cortisol and IgE levels were hypothesized in comorbid depressive AD patients. In Ps patients with comorbid depression, high serum concentrations of IL-6 and IL-18, as well as IL-17A, were presumed to act as shared inflammatory mechanisms. CONCLUSIONS Further studies should investigate mental disorders and chronic skin diseases concurrently across patients' life course and identify their temporal relation and biological correlates. Future research should also identify biological characteristics of individuals at high risk of the comorbid disorders and associated complications.
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Affiliation(s)
- Michele Fabrazzo
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138Naples, Italy
| | - Salvatore Cipolla
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138Naples, Italy
| | - Simona Signoriello
- Medical Statistics Unit, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, 80138Naples, Italy
| | - Alessio Camerlengo
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138Naples, Italy
| | - Giulia Calabrese
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80131Naples, Italy
| | - Giulia Maria Giordano
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138Naples, Italy
| | - Giuseppe Argenziano
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80131Naples, Italy
| | - Silvana Galderisi
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138Naples, Italy
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17
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Psoriatic Arthritis: The Influence of Co-morbidities on Drug Choice. Rheumatol Ther 2021; 9:49-71. [PMID: 34797530 PMCID: PMC8814223 DOI: 10.1007/s40744-021-00397-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/28/2021] [Indexed: 12/20/2022] Open
Abstract
Psoriatic arthritis (PsA) is associated with a higher burden of co-morbidities such as obesity, cardiovascular disease, non-alcoholic fatty liver disease, inflammatory eye disease, inflammatory bowel disease, skin cancer and depression compared to the general population. In the last 20 years, the therapeutic options for PsA have increased exponentially with the availability of tumor necrosis factor-alpha (TNF) inhibitors, interleukin (IL)-17 inhibitors, IL-12/23 inhibitors and Janus kinases/signal transducer and activator of transcription proteins (JAK/STAT) inhibitors. The articular and extra-articular manifestations of PsA usually dictate the treatment choice but important consideration must be given to the corresponding co-morbidities while deciding the drug therapy due to associated safety profile, effect on disease activity, etc. This review provides a comprehensive review of common co-morbidities in PsA and how they can influence treatment choices.
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18
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Nast A, Altenburg A, Augustin M, Boehncke WH, Härle P, Klaus J, Koza J, Mrowietz U, Ockenfels HM, Philipp S, Reich K, Rosenbach T, Schlaeger M, Schmid-Ott G, Sebastian M, von Kiedrowski R, Weberschock T, Dressler C. German S3-Guideline on the treatment of Psoriasis vulgaris, adapted from EuroGuiDerm - Part 2: Treatment monitoring and specific clinical or comorbid situations. J Dtsch Dermatol Ges 2021; 19:1092-1115. [PMID: 34288477 DOI: 10.1111/ddg.14507] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/06/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Alexander Nast
- Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andreas Altenburg
- Dermatology, Venereology and Allergology, Immunology Center, Dessau Municipal Hospital, Dessau, Germany
| | - Matthias Augustin
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Wolf-Henning Boehncke
- Department of Dermatology and Venereology, University Hospital of Geneva, Geneva, Switzerland
| | | | | | | | - Ulrich Mrowietz
- Psoriasis Center, Department of Dermatology, Venereology, Allergology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | | | - Kristian Reich
- Center for Translational Research in Inflammatory Skin Diseases, Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | - Tobias Weberschock
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Frankfurt/Main, Germany and Working group Evidence-based Medicine Frankfurt, Institute for General Practice, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Corinna Dressler
- Department of Dermatology, Venereology and Allergology, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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19
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Nast A, Altenburg A, Augustin M, Boehncke WH, Härle P, Klaus J, Koza J, Mrowietz U, Ockenfels HM, Philipp S, Reich K, Rosenbach T, Schlaeger M, Schmid-Ott G, Sebastian M, von Kiedrowski R, Weberschock T, Dressler C. Deutsche S3-Leitlinie zur Therapie der Psoriasis vulgaris, adaptiert von EuroGuiDerm - Teil 2: Therapiemonitoring, besondere klinische Situationen und Komorbidität. J Dtsch Dermatol Ges 2021; 19:1092-1117. [PMID: 34288473 DOI: 10.1111/ddg.14507_g] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Alexander Nast
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
| | - Andreas Altenburg
- Dermatologie, Venerologie und Allergologie, Immunologisches Zentrum, Städtisches Klinikum Dessau
| | - Matthias Augustin
- Kompetenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg
| | | | | | | | | | - Ulrich Mrowietz
- Psoriasis-Zentrum, Klinik für Dermatologie, Venerologie, Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | | | | | - Kristian Reich
- Zentrum für Translationale Forschung bei entzündlichen Hauterkrankungen, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen, Universitätsmedizin Hamburg-Eppendorf
| | | | | | | | | | | | - Tobias Weberschock
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt/Main und Arbeitsgruppe EbM Frankfurt, Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt
| | - Corinna Dressler
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin
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20
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Lambert JLW, Segaert S, Ghislain PD, Hillary T, Nikkels A, Willaert F, Lambert J, Speeckaert R. Practical recommendations for systemic treatment in psoriasis according to age, pregnancy, metabolic syndrome, mental health, psoriasis subtype and treatment history (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis; part 1). J Eur Acad Dermatol Venereol 2021; 34:1654-1665. [PMID: 32735076 PMCID: PMC7496083 DOI: 10.1111/jdv.16684] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022]
Abstract
Background Impressive progress in new therapeutic options has been made for psoriasis. Treatments include topical steroids, phototherapy, conventional, synthetic disease‐modifying drugs and an expanding list of biologics. Objective The primary objective of this work was to collect evidence for the creation of practice guidelines for systemic treatment of psoriasis (BETA‐PSO: Belgian Evidence‐based Treatment Advice in Psoriasis). Methods Evidence‐based recommendations were formulated using a quasi‐Delphi methodology after a systematic search of the literature and a consensus procedure involving 8 psoriasis experts. Results In this part, the use of systemic treatment in different age groups, during pregnancy, in metabolic syndrome, in patients with mental health problems, in different psoriasis subtypes and in previously systemically treated patients treatment is discussed. Conclusion Guidance on therapeutic choice in specific clinical situations in psoriasis is provided in order to facilitate the decision‐making in clinical practice.
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Affiliation(s)
- J L W Lambert
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | | | - P D Ghislain
- Dermatology, Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - T Hillary
- Dermatology, University Hospital Leuven, Leuven, Belgium
| | - A Nikkels
- Dermatology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - F Willaert
- Dermatology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - J Lambert
- Dermatology, University Hospital of Antwerp, Antwerp, Belgium
| | - R Speeckaert
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
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21
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Skornicki M, Prince P, Suruki R, Lee E, Louder A. Clinical Burden of Concomitant Joint Disease in Psoriasis: A US-Linked Claims and Electronic Health Records Database Analysis. Adv Ther 2021; 38:2458-2471. [PMID: 33818686 PMCID: PMC8107168 DOI: 10.1007/s12325-021-01698-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/06/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Few studies have evaluated the clinical burden of concomitant joint disease in patients with psoriasis (PSO). The objective of this study was to assess comorbidity rates in patients with psoriatic arthritis (PsA) compared with PSO alone. METHODS This was a retrospective study of US patients with prevalent PSO. Linked medical claims and electronic health records (EHR) in Optum's de-identified Integrated Claims-Clinical dataset were analyzed from 2007 to 2018. Patients were followed for up to 5 years after the first claim/diagnostic code for PSO (index date). Baseline comorbidity prevalence and follow-up rates (cases per 1000 person-years) were assessed using descriptive statistics. Comorbidity rate analysis included patients with the respective comorbidity at baseline. RESULTS Baseline demographics and comorbidity prevalence were numerically similar between patients with concomitant joint disease (PSO-PsA) and those with PSO alone (PSO-only). During follow-up, comorbidity rates were higher in patients in the PSO-PsA group than patients in the PSO-only group. Ratios of PSO-PsA comorbidity rates relative to PSO-only ranged from 1.1 for allergies and infections to 1.7 for fatigue, diabetes, and obesity. Comorbidity rate ratios increased from year 1 to year 5 for hypertension (1.05-1.34), hyperlipidemia (0.94-1.13), diabetes (1.00-1.49), cardiovascular disease (1.03-1.66), depression (0.97-1.19), and anxiety (0.87-0.98). CONCLUSIONS Patients with PsA have a larger clinical burden, characterized by higher comorbidity rates, than those with PSO. Future research should explore PsA risk factors and how physicians can monitor and treat patients with PSO to reduce the risk of PsA and the associated clinical burden.
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22
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Pisetsky DS, Eudy AM, Clowse MEB, Rogers JL. The Categorization of Pain in Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2021; 47:215-228. [PMID: 33781491 DOI: 10.1016/j.rdc.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Systemic lupus erythematous is a systemic autoimmune disease that can cause severe pain and impair quality of life. Pain in lupus can arise from a variety of mechanisms and is usually assessed in terms of activity and damage. In contrast, categorization of symptoms as type 1 and type 2 manifestations encompasses a broader array of symptoms, including widespread pain, fatigue, and depression that may track together. The categorization of symptoms as type 1 and type 2 manifestations can facilitate communication between patient and provider as well as provide a framework to address more fully the complex symptoms experienced by patients.
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Affiliation(s)
- David S Pisetsky
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA; Medical Research Service, Durham Veterans Administration Medical Center, Durham, NC, USA.
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Rogers
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA
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Nast A, Smith C, Spuls P, Avila Valle G, Bata‐Csörgö Z, Boonen H, De Jong E, Garcia‐Doval I, Gisondi P, Kaur‐Knudsen D, Mahil S, Mälkönen T, Maul J, Mburu S, Mrowietz U, Reich K, Remenyik E, Rønholt K, Sator P, Schmitt‐Egenolf M, Sikora M, Strömer K, Sundnes O, Trigos D, Van Der Kraaij G, Yawalkar N, Dressler C. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 2: specific clinical and comorbid situations. J Eur Acad Dermatol Venereol 2021; 35:281-317. [DOI: 10.1111/jdv.16926] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/13/2020] [Indexed: 12/15/2022]
Affiliation(s)
- A. Nast
- Charité – Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Dermatology, Venereology and Allergology Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - C. Smith
- St John’s Institute of Dermatology London UK
| | - P.I. Spuls
- Academic Medical Centre Amsterdam Amsterdam Netherlands
| | - G. Avila Valle
- Charité – Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Dermatology, Venereology and Allergology Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | | | - H. Boonen
- Office‐Based Dermatology Practice Geel Belgium
| | - E. De Jong
- Radboud University Medical Centre Nijmegen Nijmegen Netherlands
| | - I. Garcia‐Doval
- Unidad de Investigación. Fundación Piel Sana AEDV Madrid Spain
| | | | | | - S. Mahil
- Guy's and St Thomas' NHS Foundation Trust London UK
| | - T. Mälkönen
- Helsinki University Central Hospital Helsinki Finland
| | - J.T. Maul
- Department of Dermatology University Hospital of Zürich Zürich Switzerland
| | - S. Mburu
- International Federation of Psoriasis Associations (IFPA)
| | - U. Mrowietz
- Universitätsklinikum Schleswig‐Holstein Kiel Germany
| | - K. Reich
- Translational Research in Inflammatory Skin Diseases Institute for Health Services Research in Dermatology and Nursing University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | | | | | - P.G. Sator
- Municipal Hospital Hietzing Vienna Austria
| | - M. Schmitt‐Egenolf
- Dermatology Department of Public Health & Clinical Medicine Umeå University Umeå Sweden
| | - M. Sikora
- Department of Dermatology Medical University of Warsaw Warsaw Poland
| | - K. Strömer
- Office‐Based Dermatology Practice Mönchengladbach Germany
| | | | - D. Trigos
- International Federation of Psoriasis Associations (IFPA)
| | | | - N. Yawalkar
- Department of Dermatology, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - C. Dressler
- Charité – Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Department of Dermatology, Venereology and Allergology Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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Gałecka M, Bliźniewska-Kowalska K, Maes M, Su KP, Gałecki P. Update on the neurodevelopmental theory of depression: is there any 'unconscious code'? Pharmacol Rep 2020; 73:346-356. [PMID: 33385173 PMCID: PMC7994228 DOI: 10.1007/s43440-020-00202-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 11/17/2020] [Accepted: 11/24/2020] [Indexed: 12/27/2022]
Abstract
Depression is currently one of the most common psychiatric disorders and the number of patients receiving antidepressant treatment is increasing every year. Therefore, it is essential to understand the underlying mechanisms that are associated with higher prevalence of depression. The main component leading to the change in functioning, in the form of apathy, anhedonia, lack of motivation and sleep disturbances, is stress. This is the factor that in recent decades—due to the civilization speed, dynamic technological development as well as competitiveness and competition in relationships—significantly affects the psychophysical condition, which results in an increase in the prevalence of civilization diseases, including depression. To understand the mechanism of susceptibility to this disease, one should consider the significant role of the interaction between immune and nervous systems. Their joint development from the moment of conception is a matrix of later predispositions, both associated with the mobilization of the proinflammatory pathways (TNFα, IL-1β, IL-6) and associated with psychological coping with stress. Such an early development period is associated with epigenetic processes that are strongly marked in prenatal development up to 1 year of age and determinate the characteristic phenotype for various forms of pathology, including depression. Regarding the inflammatory hypothesis of depression, interleukin 17 (IL-17), among other proinflammatory cytokines, might play an important role in the development of depressive disorders. It is secreted by Th17 cells, crossed the placental barrier and acts on the brain structures of the fetus by increasing IL-17 receptor levels and affecting the intensity of its signaling in the brain.
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Affiliation(s)
- Małgorzata Gałecka
- Department of Psychotherapy, Medical University of Lodz, Aleksandrowska 159, 91-229, Lodz, Poland.
| | | | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kuan-Pin Su
- An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Piotr Gałecki
- Department of Adult Psychiatry, Medical University of Lodz, Lodz, Poland
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25
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Cano-García L, Mena-Vázquez N, Manrique Arija S, Hernández-Sánchez MD, Segura-Ruiz R, Domínguez-Quesada C, Fernández-Nebro A. Psychological factors associated with sleep disorders in patients with axial spondyloarthritis or psoriatic arthritis: A multicenter cross-sectional observational study. J Clin Nurs 2020; 30:266-275. [PMID: 33113279 DOI: 10.1111/jocn.15546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/26/2020] [Accepted: 10/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies in axial spondyloarthritis (AxSp) have shown that intensity of pain, anxiety, depression and inflammatory activity are associated with poor sleep quality. AIM To describe mood and sleep disorders and positive psychological factors in patients with AxSp and psoriatic arthritis (PsA) and to evaluate the psychological factors that are potentially involved in sleep disorders. DESIGN Multicenter cross-sectional observational study based on a series of patients with AxSp and PsA. PARTICIPANTS Participants were selected consecutively from patients aged ≥18 years with AxSp or PsA followed at the rheumatology department of 4 Spanish hospitals. INCLUSION CRITERIA age ≥18 years, AxSp (ASAS criteria) or PsA (CASPAR criteria), ability to understand the study and prepared to complete the questionnaires. METHODS Main outcomes: Oviedo Sleep Quality questionnaire result. SECONDARY OUTCOMES psychological status evaluated using the Hospital Anxiety and Depression Scale (HADS) questionnaire, health-related quality of life evaluated using SF-36, perception of pain evaluated using the short questionnaire for assessment of pain (BDU) and fatigue evaluated using the Fatigue Scale (FACIT) questionnaire. We performed a descriptive multivariate linear regression analysis to study factors that were independently associated with sleep disorders. The STROBE guidelines were adopted. RESULTS We included 301 patients (152 [50.5%] with AxSp and 149 [49.5%] with PsA). The multivariate linear regression analysis for the whole sample showed that insomnia was inversely associated with emotional recovery and biologic disease-modifying antirheumatic drugs and directly associated with depression in both groups. The analysis by disease (AxSp and PsA) showed that insomnia was independently associated with depression and emotional recovery. CONCLUSIONS Insomnia may be associated with other mood disorders, quality of life and inflammatory activity in the patients studied here. RELEVANCE TO CLINICAL PRACTICE A nurse intervention can be carried out to prevent sleep disorders knowing the consequences and triggers of the problem.
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Affiliation(s)
- Laura Cano-García
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Sara Manrique Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain.,Departamento de Medicina, Universidad de Málaga, Málaga, Spain
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26
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Patient-Centered Care in Psoriatic Arthritis-A Perspective on Inflammation, Disease Activity, and Psychosocial Factors. J Clin Med 2020; 9:jcm9103103. [PMID: 32992983 PMCID: PMC7600723 DOI: 10.3390/jcm9103103] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022] Open
Abstract
Psoriatic arthritis (PsA) is a seronegative spondyloarthropathy characterized by skin lesions, dactylitis, and enthesitis. Patients with PsA suffer from a variety of psychosocial difficulties and nonspecific symptoms early on in the disease course and continue to experience progressive disease due to delays in diagnosis and treatment. Symptoms initially viewed as somatization could lead to undertreatment and promote psychological distress, poor coping, and negative patient-provider relationships. Pain and fatigue are important complaints that affect the patient's perception and may need to be addressed with a multidisciplinary approach. Maladaptive cognitive responses can lead to a negative illness perception and impact patient beliefs and concerns over treatment, as well as nonadherence. An underlying inflammatory component in affective disorders has been examined, though whether and how it may interact mechanistically in PsA warrants interest. Cognitive behavioral therapy represents a nonpharmacological treatment modality that can be combined with cytokine-targeted therapy to address both somatic and psychological complaints. Future directions for research include: (1) Elucidating nonspecific manifestations (e.g., subclinical stage, differential with functional syndromes) of PsA and how they impact diagnosis and management; (2) characterizing immune-mediated components of mood disorders in PsA; and (3) whether a bidirectional approach with abrogating inflammation and psychotherapeutic support leads to improved outcomes.
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27
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Haugeberg G, Hoff M, Kavanaugh A, Michelsen B. Psoriatic arthritis: exploring the occurrence of sleep disturbances, fatigue, and depression and their correlates. Arthritis Res Ther 2020; 22:198. [PMID: 32847612 PMCID: PMC7448431 DOI: 10.1186/s13075-020-02294-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/13/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Sleep disturbances, fatigue, and anxiety/depression in psoriatic arthritis (PsA) may be influenced by skin and musculoskeletal manifestations. All of these in turn affect the psychosocial impact of disease. The objective was to explore the occurrence of sleep disturbances, fatigue, and anxiety/depression in psoriatic arthritis (PsA) patients, and their correlates. Methods A broad data collection was performed in 137 Norwegian PsA outpatient clinic patients including demographics, disease activity measures for both skin and musculoskeletal involvement, and patient-reported outcome measures. Sleep disturbances and fatigue were defined present if the numeric rating scale (0–10) score was ≥ 5. Anxiety/depression was assessed using a questionnaire (1–3; 1 defined as no anxiety/depression). Descriptive statistics was applied, and associations were explored using univariate and adjusted linear regression analysis. Results The mean age was 52.3 years, PsA disease duration 8.8 years; 49.6% were men and 54.8% were currently employed/working. The prevalence of sleep disturbances was 38.0%, fatigue 44.5%, and anxiety/depression 38.0%. In adjusted analysis, pain, fatigue, and higher mHAQ were associated with sleep disturbances. Sleep disturbances, pain, and anxiety/depression were associated with fatigue, whereas only fatigue was associated with anxiety/depression. Conclusions The prevalence of sleep disturbances, fatigue, and anxiety/depression was frequently reported by PsA patients. No measures reflecting skin involvement or objective measures of musculoskeletal involvement were independently associated with sleep disturbances, fatigue, or anxiety/depression. Our data suggest that patients’ perceptions of musculoskeletal involvement (pain or mHAQ) play an important role causing sleep disturbances and fatigue, whereas fatigue in PsA patients is strongly associated with anxiety/depression.
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Affiliation(s)
- Glenn Haugeberg
- Division of Rheumatology, Department of Medicine, Sorlandet Hospital, P.O.Box 416, N-4604, Kristiansand S, Norway. .,Department of Neuroscience, Division of Rheumatology, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Mari Hoff
- Department of Neuroscience, Division of Rheumatology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arthur Kavanaugh
- Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Brigitte Michelsen
- Division of Rheumatology, Department of Medicine, Sorlandet Hospital, P.O.Box 416, N-4604, Kristiansand S, Norway
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28
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Mathew AJ, Chandran V. Depression in Psoriatic Arthritis: Dimensional Aspects and Link with Systemic Inflammation. Rheumatol Ther 2020; 7:287-300. [PMID: 32323218 PMCID: PMC7211219 DOI: 10.1007/s40744-020-00207-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Indexed: 12/12/2022] Open
Abstract
Studying comorbidities in patients with psoriatic arthritis (PsA) provides a better understanding of the extended burden of the disease. Depression and anxiety are well recognized but understudied comorbidities in patients with PsA. The prevalence of depression is significantly higher in this patient population than in the general population, with far reaching consequences in terms of long-term quality of life. Over the past few years there has been an increasing interest in the link between inflammation and depression, with several novel studies being conducted. Recent evidence suggests a significant improvement of depression in PsA patients treated with biologic disease-modifying anti-rheumatic drugs (bDMARDs) as compared to conventional DMARDs. Depression in PsA is multidimensional, with recognized phenotypes, including cognitive disorder, alexithymia and anhedonia. The paucity of standardized, validated tools to screen these dimensional phenotypes remains an unmet need. Prevalence studies on depression in patients with PsA, mostly based on patient-reported outcomes, are only able to highlight the tip of the iceberg. A comprehensive, multi-disciplinary approach addressing the subdomains of depression is imperative for a better understanding of depression in PsA patients, as well as to find a way forward for improving their quality of life. In this scoping review, we explore existing evidence on the burden of depression in PsA patients, the link between inflammation and depression in these patients and the screening tools used to evaluate the subdomains of depression.
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Affiliation(s)
- Ashish J Mathew
- The Psoriatic Disease Program, Centre for Prognosis Studies in the Rheumatic Diseases, Krembil Research Institute, University Health Network, Toronto, Canada
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - Vinod Chandran
- The Psoriatic Disease Program, Centre for Prognosis Studies in the Rheumatic Diseases, Krembil Research Institute, University Health Network, Toronto, Canada.
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
- Institute of Medical Science, University of Toronto, Toronto, Canada.
- Department of Medicine, Memorial University, St. John's, Canada.
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29
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Founta O, Adamzik K, Tobin AM, Kirby B, Hevey D. Psychological Distress, Alexithymia and Alcohol Misuse in Patients with Psoriasis: A Cross-Sectional Study. J Clin Psychol Med Settings 2020; 26:200-219. [PMID: 30206746 DOI: 10.1007/s10880-018-9580-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This study investigates (a) the prevalence of psychological distress, alexithymia and alcohol misuse in psoriasis patients; and (b) the relationship between psoriasis severity, alexithymia, alcohol and psychological distress in patients with psoriasis. A cross-sectional study was conducted. Outpatients (n = 184) with moderate to severe psoriasis completed a psychological screening battery. Measures included the Hospital Anxiety and Depression Scale, the Penn State Worry Questionnaire, the twenty-item Toronto Alexithymia Scale, the Dermatology Life Quality Index, the Psoriasis Area and Severity Index, the Self-Administered Psoriasis Area and Severity Index, and the Alcohol Use Disorders Identification Test. Demographic, clinical details and information on knowledge of psychosocial issues, alcohol and confidence on coping with distress and talking to others about psoriasis was also gathered. Alexithymia was associated with anxiety, depression and worry; subjective psoriasis severity was associated with worry. Alcohol misuse was related to anxiety and worry, but not to depression. Appropriate identification and treatment of alcohol difficulties and psychological distress of patients with psoriasis is needed.
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Affiliation(s)
- Ourania Founta
- Research Centre for Psychological Health, School of Psychology, Trinity College Dublin, Dublin 2, Ireland.
| | - Karoline Adamzik
- Dermatology Department, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Anne-Marie Tobin
- Dermatology Department, The Adelaide & Meath Hospital, Tallaght, Dublin 24, Ireland
| | - Brian Kirby
- Dermatology Department, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.,Charles Department of Dermatology, St Vincent's University Hospital and School of Health Sciences, UCD, Dublin 4, Ireland
| | - David Hevey
- Research Centre for Psychological Health, School of Psychology, Trinity College Dublin, Dublin 2, Ireland
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30
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Maliyar K, Fleming P, Ogunyemi B, Lynde C. A Brief History of Psoriasis Management in Canada. J Cutan Med Surg 2020; 24:273-277. [DOI: 10.1177/1203475420903682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Psoriasis is a chronic, inflammatory disease with a varying degree of clinical presentations. Managing psoriasis has always been arduous due to its chronicity and its propensity to relapse. Prior to the development of targeted biologic therapies, there were few effective treatments for psoriasis. Ancient psoriasis therapies included pinetar, plant extracts, psychotherapy, arsenic, and ammoniated mercury. In the 19th century, chrysarobin was developed. Then, in the early half of the 20th century, anthralin and coal tar were in widespread use. In the latter half of the 20th century, treatments were limited to topical first-line therapies, systemic drugs, and phototherapy. However, as the treatment of psoriasis has undergone a revolutionary change with the development of novel biologic therapies, patients with moderate to severe psoriasis have been able to avail therapies with high efficacy and durability along with an acceptable safety profile. This article is a brief historical review of the management of psoriasis prior to the inception of biologics and with the development of novel biologic therapies.
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Affiliation(s)
- Khalad Maliyar
- Department of Medicine, University of Toronto, ON, Canada
| | | | - Boluwaji Ogunyemi
- Discipline of Medicine, Memorial University of Newfoundland, St. John’s, NL, Canada
| | - Charles Lynde
- Division of Dermatology, University of Toronto, ON, Canada
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31
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Kowalczyk M, Szemraj J, Bliźniewska K, Maes M, Berk M, Su KP, Gałecki P. An immune gate of depression - Early neuroimmune development in the formation of the underlying depressive disorder. Pharmacol Rep 2019; 71:1299-1307. [PMID: 31706254 DOI: 10.1016/j.pharep.2019.05.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 12/14/2022]
Abstract
The prevalence of depression worldwide is increasing from year to year and constitutes a serious medical, economic and social problem. Currently, despite multifactorial risk factors and pathways contributing to depression development, a significant aspect is attributed to the inflammatory process. Cytokines are considered a factor activating the kynurenine pathway, which leads to the exhaustion of tryptophan in the tryptophan catabolite (TRYCAT) pathway. This results in the activation of potentially neuroprogressive processes and also affects the metabolism of many neurotransmitters. The immune system plays a coordinating role in mediating inflammatory process. Beginning from foetal life, dendritic cells have the ability to react to bacterial and viral antigens, stimulating T lymphocytes in a similar way to adult cells. Cytotoxicity in the prenatal period shapes the predisposition to the development of depression in adult life. Allostasis, i.e. the ability to maintain the body's balance in the face of environmental adversity through changes in its behaviour or physiology, allows the organism to survive but its consequences may be unfavourable if it lasts too long. As a result, Th lymphocytes, in particular T helper 17 cells, which play a central role in the immunity of the whole body, contribute to the development of both autoimmune diseases and psychiatric disorders including depression, as well as have an impact on the differentiation of T CD4+ cells into Th17 cells in the later development of the child's organism, which confirms the importance of the foetal period for the progression of depressive disorders.
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Affiliation(s)
| | - Janusz Szemraj
- Department of Medical Biochemistry, Medical University of Lodz, Łódź, Poland
| | | | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michael Berk
- IMPACT Strategic Research Centre, Deakin University School of Medicine, and Barwon Health, Geelong, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, The Department of Psychiatry and The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Kuan-Pin Su
- Department of Psychiatry and Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan
| | - Piotr Gałecki
- Department of Adult Psychiatry, Medical University of Lodz, Łódź, Poland
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32
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Martínez-Ortega JM, Nogueras P, Muñoz-Negro JE, Gutiérrez-Rojas L, González-Domenech P, Gurpegui M. Quality of life, anxiety and depressive symptoms in patients with psoriasis: A case-control study. J Psychosom Res 2019; 124:109780. [PMID: 31443809 DOI: 10.1016/j.jpsychores.2019.109780] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare quality of life (QoL), anxiety and depressive symptoms, alcohol consumption and other correlates between patients with psoriasis and controls; and to identify features of psoriasis associated with lower levels of QoL. METHOD Case-control study including 70 subjects with moderate-severe psoriasis and 140 controls without psoriasis. All participants answered the Short Form Health Survey (SF-36), with physical and mental component scores of quality of life, and the Hospital Anxiety and Depression Scale (HADS). Among subjects with psoriasis, the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI) were used, respectively, to measure the severity of psoriasis and the impact of psoriasis on the specific quality of life. RESULTS Compared to controls, patients with psoriasis showed higher HADS depression score and alcohol consumption, and lower QoL. Among subjects with psoriasis, multivariate analysis showed: 1) poorer physical QoL was associated with older age, articular lesions and anxious symptoms, whereas poorer mental QoL was associated with younger age, female sex, genital lesions and depressive symptoms; 2) the higher the severity of psoriasis, the lower the level of QoL and the higher the levels of anxious or depressive symptoms; and 3) female sex and articular or genital location of lesions are linked with higher HADS scores. CONCLUSION Higher scores in anxiety and depression and lower QoL is common in psoriasis, especially among women and those with genital or articular lesions. Dermatologists should give special attention to this subgroup of persons with psoriasis in order to prevent future psychopathology.
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Affiliation(s)
- José M Martínez-Ortega
- Department of Psychiatry, University of Granada, Granada, Spain; CTS-549 Research Group, Institute of Neurosciences, University of Granada, Granada, Spain
| | - Paloma Nogueras
- Dermatology Service, Virgen de la Nieves University Hospital, Granada, Spain
| | - José E Muñoz-Negro
- Department of Psychiatry, University of Granada, Granada, Spain; UGC Salud Mental, San Cecilio University Hospital and ibs Granada, Spain
| | - Luis Gutiérrez-Rojas
- Department of Psychiatry, University of Granada, Granada, Spain; CTS-549 Research Group, Institute of Neurosciences, University of Granada, Granada, Spain; UGC Salud Mental, San Cecilio University Hospital and ibs Granada, Spain.
| | | | - Manuel Gurpegui
- Department of Psychiatry, University of Granada, Granada, Spain; CTS-549 Research Group, Institute of Neurosciences, University of Granada, Granada, Spain
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33
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Yang A, Xin X, Yang W, Li M, Yang W, Li L, Liu X. Etanercept reduces anxiety and depression in psoriasis patients, and sustained depression correlates with reduced therapeutic response to etanercept. Ann Dermatol Venereol 2019; 146:363-371. [PMID: 31047699 DOI: 10.1016/j.annder.2019.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 01/01/2019] [Accepted: 03/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The purpose of this study was to explore the correlation of anxiety and depression with therapeutic response to etanercept in psoriasis patients. PATIENTS AND METHODS One hundred and thirty-three patients with moderate-to-severe plaque psoriasis undergoing etanercept treatment were consecutively enrolled in this prospective cohort study, with all patients receiving etanercept treatment for 6 months. Psoriasis Area and Severity Index (PASI) score was evaluated at baseline (M0) and at month 1 (M1), M3 and M6 after treatment, and PASI 75/90 responses were calculated. The Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score and the HADS-Depression (HADS-D) score were used to evaluate patients' anxiety and depression at M0, M1, M3 and M6. Sustained anxiety/depression were defined as HADS-A/D score≥8points both at M0 and M1. RESULTS Female gender and higher PASI score were associated with high risk of anxiety, while female gender, higher PASI score and longer disease duration were correlated with increased depression risk. After 6 months of etanercept treatment, 65.4% and 36.1% patients achieved PASI 75 and PASI 90 responses respectively, and both HADS-A and HADS-D scores were decreased. Most importantly, no correlation of baseline anxiety and depression with PASI 75 or PASI 90 response after 6 months of treatment was noted, while sustained depression, though not sustained anxiety, was observed to be correlated with decreased PASI 75 and PASI 90 responses. CONCLUSIONS Etanercept reduces anxiety and depression in psoriasis patients, and sustained depression correlates with reduced therapeutic response to etanercept.
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Affiliation(s)
- A Yang
- Department of Dermatology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Xin
- Department of Dermatology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - W Yang
- Department of Dermatology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - M Li
- Department of Dermatology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - W Yang
- Department of Dermatology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - L Li
- Department of Dermatology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Liu
- Department of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, 246, Xuefu road, 150001 Harbin, China.
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34
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Brain tumor necrosis factor-α mediates anxiety-like behavior in a mouse model of severe obesity. Brain Behav Immun 2019; 77:25-36. [PMID: 30508579 DOI: 10.1016/j.bbi.2018.11.316] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/22/2018] [Accepted: 11/28/2018] [Indexed: 12/18/2022] Open
Abstract
Although the high prevalence of anxiety in obesity increasingly emerges as significant risk factor for related severe health complications, the underlying pathophysiological mechanisms remain poorly understood. Considering that chronic inflammation is a key component of obesity and is well known to impact brain function and emotional behavior, we hypothesized that it may similarly contribute to the development of obesity-related anxiety. This hypothesis was experimentally tested by measuring whether chronic food restriction, a procedure known to reduce inflammation, or chronic anti-inflammatory treatment with ibuprofen improved anxiety-like behavior and concomitantly decreased peripheral and/or hippocampal inflammation characterizing a model of severe obesity, the db/db mice. In both experiments, reduced anxiety-like behaviors in the open-field and/or elevated plus-maze were selectively associated with decreased hippocampal tumor necrosis factor-α (TNF-α) mRNA expression. Highlighting the causality of both events, chronic central infusion of the TNF-α blocker etanercept was then shown to be sufficient to improve anxiety-like behavior in db/db mice. Lastly, by measuring the impact of ex-vivo etanercept on hippocampal synaptic processes underlying anxiety-like behaviors, we showed that the anxiolytic effect of central TNF-α blockade likely involved modulation of synaptic transmission within the ventral hippocampus. Altogether, these results uphold the role of brain TNF-α in mediating obesity-related anxiety and provide important clues about how it may modulate brain function and behavior. They may therefore help to introduce novel therapeutic strategies to reduce anxiety associated with inflammatory conditions.
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Brás JP, Pinto S, Almeida MI, Prata J, von Doellinger O, Coelho R, Barbosa MA, Santos SG. Peripheral Biomarkers of Inflammation in Depression: Evidence from Animal Models and Clinical Studies. Methods Mol Biol 2019; 2011:467-492. [PMID: 31273717 DOI: 10.1007/978-1-4939-9554-7_28] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Depression is a highly prevalent psychiatric condition, with over 300 million sufferers, and is an important comorbidity for other conditions, like cardiovascular disorders or diabetes. Therapy is largely based on psychotherapy and/or pharmacological intervention, particularly aimed at altering neurotransmitter levels in the central nervous system, but inadequate response to treatment remains a significant clinical problem. Herein, evidence supporting a molecular link between inflammation and depression will be discussed, particularly the increased prevalence of depression in chronic inflammatory diseases and the evidence on the use of anti-inflammatory drugs to treat depression. Moreover, the potential for the levels of peripheral inflammatory molecules to act as depression biomarkers, in the diagnosis and monitoring of depression will be examined, considering clinical- and animal model-based evidence.
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Affiliation(s)
- J P Brás
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- INEB-Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal
- ICBAS-Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - S Pinto
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- FMUP-Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Centro Hospitalar Universitário São João, Porto, Portugal
| | - M I Almeida
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- INEB-Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal
| | - J Prata
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- FMUP-Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Psychiatry and Mental Health, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - O von Doellinger
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- FMUP-Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Psychiatry and Mental Health, Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - R Coelho
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- FMUP-Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Centro Hospitalar Universitário São João, Porto, Portugal
| | - M A Barbosa
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- INEB-Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal
- ICBAS-Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - S G Santos
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal.
- INEB-Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal.
- ICBAS-Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal.
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Psoriasis and Depression: The Role of Inflammation. ACTAS DERMO-SIFILIOGRAFICAS 2018; 110:12-19. [PMID: 30509759 DOI: 10.1016/j.ad.2018.05.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/07/2018] [Accepted: 05/28/2018] [Indexed: 12/22/2022] Open
Abstract
Psoriasis is a chronic, systemic inflammatory disorder with multiple comorbidities. The most common comorbidities are mental disorders, especially depression, which can interact negatively with psoriasis to produce a dangerous vicious circle. Depression in psoriasis has traditionally been explained as a response to psychosocial factors and impaired quality of life. However, a new hypothesis linking depression and psoriasis through chronic inflammation offers insights that should help to understand and treat these diseases. In this approach, new drugs and lifestyle have an important role.
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Interleukin 17 and Treg - a common pathomechanism and a new target of therapy in rheumatic diseases and depression. Reumatologia 2018; 56:201-202. [PMID: 30237623 PMCID: PMC6142021 DOI: 10.5114/reum.2018.77969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 08/08/2018] [Indexed: 01/26/2023] Open
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Holahan HM, Farah RS, Fitz S, Mott SL, Ferguson NN, McKillip J, Link B, Liu V. Health-related quality of life in patients with cutaneous T-cell lymphoma? Int J Dermatol 2018; 57:1314-1319. [DOI: 10.1111/ijd.14132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 05/31/2018] [Accepted: 06/13/2018] [Indexed: 01/21/2023]
Affiliation(s)
- Heather M. Holahan
- Rutgers-New Jersey Medical School; Department of Dermatology; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Ronda S. Farah
- Department of Dermatology; University of Minnesota; Minneapolis MN USA
| | - Sara Fitz
- Medical Associates Clinic & Health Plans; Dubuque IA USA
| | - Sarah L. Mott
- University of Iowa Hospitals and Clinics; Holden Comprehensive Cancer Center; Iowa City IA USA
| | - Nkanyezi N. Ferguson
- Department of Dermatology; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Julie McKillip
- Department of Dermatology; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Brian Link
- Department of Internal Medicine-Hematology, Oncology, and Blood and Marrow Transplantation; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Vincent Liu
- Departments of Dermatology and Pathology; University of Iowa Hospitals and Clinics; Iowa City IA USA
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Kranaster L, Hoyer C, Aksay SS, Bumb JM, Müller N, Zill P, Schwarz MJ, Sartorius A. Antidepressant efficacy of electroconvulsive therapy is associated with a reduction of the innate cellular immune activity in the cerebrospinal fluid in patients with depression. World J Biol Psychiatry 2018; 19:379-389. [PMID: 28714751 DOI: 10.1080/15622975.2017.1355473] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES A bidirectional link between the antidepressant effects of electroconvulsive therapy (ECT) and the modulation of the immune system has been proposed. To elucidate the interplay between antidepressant treatment and macrophage/microglia activation in humans, we performed a study on the effects of the antidepressant treatment by ECT on markers of macrophage/microglia activation in patients with depression. METHODS We measured six different markers (IL-6, neopterin, sCD14, sCD163 MIF and MCP1) of macrophage/microglia activation in the cerebrospinal fluid (CSF) and blood of 12 patients with a severe, treatment-resistant depressive episode before and after a course of ECT. RESULTS Some markers in the CSF of remitters were reduced after the ECT course and differed from non-remitters, but no differences were found before and after ECT independently from the antidepressant efficacy. CSF baseline levels of some markers could predict the reduction of depressive psychopathology during ECT. Higher CSF levels indicating increased macrophage/microglia activation at baseline predicted a better treatment response to ECT. CONCLUSIONS Although the sample size was small, our data suggest that macrophages/microglia are involved in the pathophysiology of major depression and that antidepressant efficacy by ECT might be partly explained by the modulation of the innate immune system within the brain.
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Affiliation(s)
- Laura Kranaster
- a Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim , Heidelberg University , Mannheim , Germany
| | - Carolin Hoyer
- b Department of Neurology , University Medical Centre Mannheim , Mannheim , Germany
| | - Suna S Aksay
- a Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim , Heidelberg University , Mannheim , Germany
| | - Jan Malte Bumb
- c Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim , Heidelberg University , Mannheim , Germany
| | - Norbert Müller
- d Department of Psychiatry and Psychotherapy , Ludwig Maximilian University Munich , Munich , Germany
| | - Peter Zill
- d Department of Psychiatry and Psychotherapy , Ludwig Maximilian University Munich , Munich , Germany
| | - Markus J Schwarz
- e Department of Laboratory Medicine , Ludwig Maximilian University Munich , Munich , Germany
| | - Alexander Sartorius
- a Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim , Heidelberg University , Mannheim , Germany
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Vancassel S, Capuron L, Castanon N. Brain Kynurenine and BH4 Pathways: Relevance to the Pathophysiology and Treatment of Inflammation-Driven Depressive Symptoms. Front Neurosci 2018; 12:499. [PMID: 30140200 PMCID: PMC6095005 DOI: 10.3389/fnins.2018.00499] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/03/2018] [Indexed: 12/13/2022] Open
Abstract
The prevalence of depressive disorders is growing worldwide, notably due to stagnation in the development of drugs with greater antidepressant efficacy, the continuous large proportion of patients who do not respond to conventional antidepressants, and the increasing rate of chronic medical conditions associated with an increased vulnerability to depressive comorbidities. Accordingly, better knowledge on the pathophysiology of depression and mechanisms underlying depressive comorbidities in chronic medical conditions appears urgently needed, in order to help in the development of targeted therapeutic strategies. In this review, we present evidence pointing to inflammatory processes as key players in the pathophysiology and treatment of depressive symptoms. In particular, we report preclinical and clinical findings showing that inflammation-driven alterations in specific metabolic pathways, namely kynurenine and tetrahydrobiopterin (BH4) pathways, leads to substantial alterations in the metabolism of serotonin, glutamate and dopamine that are likely to contribute to the development of key depressive symptom dimensions. Accordingly, anti-inflammatory interventions targeting kynurenine and BH4 pathways may be effective as novel treatment or as adjuvants of conventional medications rather directed to monoamines, notably when depressive symptomatology and inflammation are comorbid in treated patients. This notion is discussed in the light of recent findings illustrating the tight interactions between known antidepressant drugs and inflammatory processes, as well as their therapeutic implications. Altogether, this review provides valuable findings for moving toward more adapted and personalized therapeutic strategies to treat inflammation-related depressive symptoms.
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Affiliation(s)
- Sylvie Vancassel
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), INRA, Bordeaux, France
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), Bordeaux University, Bordeaux, France
| | - Lucile Capuron
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), INRA, Bordeaux, France
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), Bordeaux University, Bordeaux, France
| | - Nathalie Castanon
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), INRA, Bordeaux, France
- UMR 1286, Laboratory of Nutrition and Integrative Neurobiology (NutriNeuro), Bordeaux University, Bordeaux, France
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Gordon KB, Armstrong AW, Han C, Foley P, Song M, Wasfi Y, You Y, Shen YK, Reich K. Anxiety and depression in patients with moderate-to-severe psoriasis and comparison of change from baseline after treatment with guselkumab vs. adalimumab: results from the Phase 3 VOYAGE 2 study. J Eur Acad Dermatol Venereol 2018; 32:1940-1949. [PMID: 29706008 DOI: 10.1111/jdv.15012] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 03/28/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Anxiety and depression are clinically significant comorbidities associated with psoriasis. Improvements in psoriasis are known to decrease anxiety and depression. Guselkumab, an anti-interleukin-23 monoclonal antibody, has demonstrated efficacy and safety for the treatment of moderate-to-severe psoriasis. OBJECTIVE Assess improvements in anxiety and depression with guselkumab vs. placebo and adalimumab using the Hospital Anxiety and Depression Scale (HADS). METHODS In VOYAGE 2, a Phase 3, randomized, double-blind, placebo- and adalimumab-controlled study, patients received placebo (through week 16 followed by crossover to guselkumab), guselkumab, or adalimumab through week 24. HADS consists of two subscales measuring anxiety (HADS-A) and depression (HADS-D), with scores ranging from 0 to 21 and higher scores indicating more severe symptoms. Scores ≥8 indicate instrument-defined anxiety or depression. Severity of psoriasis was assessed using the Psoriasis Area and Severity Index (PASI). RESULTS Among 989 patients randomized (with baseline HADS measurements), mean HADS-A and HADS-D scores were 6.8 ± 4.2 and 5.3 ± 4.2, respectively; 38.6% of patients reported HADS-A ≥8 and 27.7% HADS-D ≥8 at baseline. At week 16, a significantly greater proportion of guselkumab patients with baseline HADS-A or HADS-D ≥8 reported HADS-A <8 (51.4% vs. 25.9%; P < 0.001) or HADS-D <8 (59.2% vs. 27.0%; P < 0.001) vs. placebo patients. At week 24, a greater proportion of guselkumab patients with baseline HADS-A or HADS-D ≥8 reported HADS-A <8 (58.4% vs. 42.9%; P = 0.028) or HADS-D <8 (59.8% vs. 46.4%; P = 0.079) vs. adalimumab patients. PASI improvements correlated with improvement in anxiety (r = 0.27; P < 0.0001) and depression (r = 0.25; P < 0.0001) scores in patients with baseline HADS-A or HADS-D ≥8. Greater improvements in HADS were also observed at week 16 in guselkumab-treated patients vs. placebo using a more stringent cut-off of HADS ≥11. CONCLUSION Guselkumab treatment was associated with greater improvements in symptoms of anxiety and depression scores in patients with psoriasis compared with placebo and adalimumab.
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Affiliation(s)
- K B Gordon
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - A W Armstrong
- University of Southern California, Los Angeles, CA, USA
| | - C Han
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - P Foley
- The University of Melbourne, St. Vincent's Hospital Melbourne, Skin & Cancer Foundation Inc., Carlton, VIC, Australia
| | - M Song
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Y Wasfi
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Y You
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Y-K Shen
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - K Reich
- Dermatologikum Berlin, Berlin, Germany
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Griffiths CEM, Fava M, Miller AH, Russell J, Ball SG, Xu W, Acharya N, Rapaport MH. Impact of Ixekizumab Treatment on Depressive Symptoms and Systemic Inflammation in Patients with Moderate-to-Severe Psoriasis: An Integrated Analysis of Three Phase 3 Clinical Studies. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:260-267. [PMID: 28903122 DOI: 10.1159/000479163] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/01/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Depression is a common comorbidity in psoriasis, and both conditions are associated with systemic inflammation. The efficacy of ixekizumab, a high-affinity monoclonal antibody that selectively targets interleukin (IL)-17A, was evaluated in patients with moderate-to-severe plaque psoriasis (psoriasis) and depressive symptoms that were at least moderately severe. METHODS Data were integrated from 3 randomized, double-blind, controlled phase 3 trials. At baseline and week 12, depressive symptoms and inflammation were assessed by the 16-item Quick Inventory of Depressive Symptomology - Self-Report (QIDS-SR16) and by a high-sensitivity assay of serum C-reactive protein (hsCRP), respectively. A subgroup of patients with at least moderately severe depressive symptoms at baseline (QIDS-SR16 total score ≥11) was analyzed. Improvement in psoriasis was assessed by the Psoriasis Area and Severity Index (PASI). RESULTS Approximately 10% of the overall psoriasis population had at least moderately severe depressive symptoms at baseline. At week 12, comorbid patients treated with ixekizumab had significantly greater improvements in their QIDS-SR16 total score (ixekizumab 80 mg every 2 weeks [Q2W], -7.1; ixekizumab 80 mg every 4 weeks [Q4W], -6.1) vs. placebo (-3.4) (p < 0.001, both comparisons) and higher rates of remission of depressive symptoms (ixekizumab Q2W, 45.2%; ixekizumab Q4W, 33.6%) vs. placebo (17.8%) (p ≤ 0.01, both comparisons). Patients treated with ixekizumab also had significant reductions in hsCRP and PASI compared to placebo. Etanercept treatment was not associated with significant improvements in depressive symptoms compared to placebo. CONCLUSIONS In this comorbid population, 12 weeks of ixekizumab therapy resulted in remission of depression for approximately 40% of patients and improved systemic inflammation as indicated by hsCRP.
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Affiliation(s)
- Christopher E M Griffiths
- Dermatology Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Sator P. Safety and tolerability of adalimumab for the treatment of psoriasis: a review summarizing 15 years of real-life experience. Ther Adv Chronic Dis 2018; 9:147-158. [PMID: 30065812 DOI: 10.1177/2040622318772705] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/23/2018] [Indexed: 12/15/2022] Open
Abstract
Biologic therapies like adalimumab are the gold standard for psoriasis treatment with efficacy and safety profiles allowing for long-term treatment. However, adalimumab cannot be used in all patients and may cause adverse drug reactions. This study reviews conditions that might limit the use of adalimumab under real-life conditions. Local injection site reactions affect 12-37% of patients but rarely require specific therapy. Dermatological adverse events (AEs) include the paradoxical psoriasis and tend to respond to adequate therapy without adalimumab discontinuation. Adalimumab increases the risk for infections; latent chronic infections like tuberculosis or hepatitis B/C impose the highest risk for serious AEs. However, administration of adalimumab may still be possible under appropriate monitoring or prophylactic therapy. Some studies indicate an increased risk of malignancies in patients with psoriasis exposed to adalimumab. Here, the causal relationship is unclear since both psoriasis and some first-line therapies increase the risk of malignancies. Depression frequently coincides with psoriasis and may respond to adalimumab as well. Cardiovascular diseases are contraindications for adalimumab, but evidence suggests that adalimumab may still be a treatment option. Overall AE rates range from 245 to 399 per 100 patient years (serious AEs: 6-23; death: 1-2). Thus, adalimumab is slightly less safe than ustekinumab and infliximab but exhibits superior effectiveness and drug survival. Adalimumab is safe for pregnant women during the first trimester, for children up to 4 years and for the elderly. Thus, in spite of several conditions that require specific attention, the favourable safety and tolerability of adalimumab for the treatment of psoriasis is confirmed.
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Affiliation(s)
- Paul Sator
- Department for Dermatology, Krankenhaus Hietzing, Austria
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Kim SJ, Park MY, Pak K, Han J, Kim GW, Kim HS, Ko HC, Kim MB, Kim BS. Improvement of depressive symptoms in patients with moderate-to-severe psoriasis treated with ustekinumab: an open label trial validated using beck depression inventory, Hamilton depression rating scale measures and 18fluorodeoxyglucose (FDG) positron emission tomography (PET). J DERMATOL TREAT 2018; 29:761-768. [PMID: 29658378 DOI: 10.1080/09546634.2018.1466021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Psoriasis is a chronic skin disease associated with psychiatric co-morbidities, especially depression. Early detection of psychological vulnerability in patients with psoriasis seems to be of great clinical importance and significantly impacts the quality of life of the patients. OBJECTIVES We sought to clarify the association between psoriasis and depressive symptoms in patients with moderate-to-severe psoriasis, and to determine the risk factors for depressive symptoms and analyze the effect of ustekinumab on the symptoms. We also aimed to evaluate the changes in glucose metabolism using 18fluorodeoxyglucose (FDG) positron emission tomography (FDG-PET). METHODS Fifteen patients with moderate-to-severe psoriasis scheduled to be treated with ustekinumab were enrolled. At baseline and after achieving a 75% reduction in the Psoriasis Area and Severity Index (PASI) score (PASI75), all patients underwent a psychiatric interview and FDG-PET. Fifteen healthy volunteers were enrolled for comparison. RESULTS Patients with moderate-to-severe psoriasis were more depressed than those in the control group were (p < .05). The severity of psoriasis at baseline did not correlate with the depression symptoms. Treatment with ustekinumab significantly reduced the depressive symptoms, as verified using Beck Depression Inventory and Hamilton Depression Rating Scale psychiatric interviews (p < .05). However, FDG-PET of the brain showed no significant difference before and after PASI75 achievement using ustekinumab injection. CONCLUSIONS Patients with moderate-to-severe psoriasis are at an increased risk for depressive symptoms, and treatment with ustekinumab may be beneficial. FDG-PET does not reflect the changes in depressive symptoms in such patients.
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Affiliation(s)
- Seong-Jang Kim
- a Department of Nuclear Medicine, School of Medicine , Pusan National University , Busan , Korea
| | - Min-Young Park
- b Department of Dermatology, School of Medicine , Pusan National University , Busan , Korea
| | - Kyoungjune Pak
- a Department of Nuclear Medicine, School of Medicine , Pusan National University , Busan , Korea
| | - Junhee Han
- c Department of Statistics and Institute of Statistics , Hallym University , Chuncheon , Korea
| | - Gun-Wook Kim
- b Department of Dermatology, School of Medicine , Pusan National University , Busan , Korea
| | - Hoon-Soo Kim
- b Department of Dermatology, School of Medicine , Pusan National University , Busan , Korea
| | - Hyun-Chang Ko
- b Department of Dermatology, School of Medicine , Pusan National University , Busan , Korea
| | - Moon-Bum Kim
- b Department of Dermatology, School of Medicine , Pusan National University , Busan , Korea.,d Biomedical Research Institute, Pusan National University Hospital , Busan , Korea
| | - Byung-Soo Kim
- b Department of Dermatology, School of Medicine , Pusan National University , Busan , Korea.,d Biomedical Research Institute, Pusan National University Hospital , Busan , Korea
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Butt H, Butt S, Hopkins C. Beyond the burn: psychosocial factors as well as inflammation moderate depression in psoriasis. J Eur Acad Dermatol Venereol 2018; 32:e171-e172. [DOI: 10.1111/jdv.14674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- H.S. Butt
- Prospect Park Hospital; Berkshire NHS Foundation Trust; Reading UK
| | - S.T. Butt
- Royal Berkshire Hospital; Royal Berkshire NHS Foundation Trust; Reading UK
| | - C.W.P. Hopkins
- Prospect Park Hospital; Berkshire NHS Foundation Trust; Reading UK
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Depressive symptoms, depression, and the effect of biologic therapy among patients in Psoriasis Longitudinal Assessment and Registry (PSOLAR). J Am Acad Dermatol 2018; 78:70-80. [DOI: 10.1016/j.jaad.2017.08.051] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/18/2017] [Accepted: 08/24/2017] [Indexed: 11/17/2022]
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Shadanbaz S. Developments in the Treatment and Management of Psoriasis. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10314000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The oral session consisted of a talk on the 2-year efficacy and safety of guselkumab in the treatment of moderate-to-severe psoriasis from the Phase III VOYAGE 1 trial. This was followed by an oral session consisting of presentations regarding the clinical efficacy of tildrakizumab in patients with chronic plaque psoriasis over 2 years of treatment, presented from the two Phase III trials, reSURFACE 1 and 2. In the poster session, data were presented on the association between psoriasis and severity index measures, the distribution of improvement measures in psoriasis, and the efficacy of guselkumab in treatment-experienced patients, as well as its impact on the comorbidities of anxiety and depression.
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Sun Y, Wang D, Salvadore G, Hsu B, Curran M, Casper C, Vermeulen J, Kent JM, Singh J, Drevets WC, Wittenberg GM, Chen G. The effects of interleukin-6 neutralizing antibodies on symptoms of depressed mood and anhedonia in patients with rheumatoid arthritis and multicentric Castleman's disease. Brain Behav Immun 2017; 66:156-164. [PMID: 28676350 DOI: 10.1016/j.bbi.2017.06.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/11/2017] [Accepted: 06/25/2017] [Indexed: 12/11/2022] Open
Abstract
Cytokines, including interleukin-6 (IL-6), modulate neuronal plasticity and stress coping. Depressive symptoms and major depressive disorder (MDD) have been associated with changes in cytokines and their signaling. The current study examined the effect of IL-6 monoclonal antibody administration on depressive symptoms in patients with rheumatoid arthritis (RA) or multicentric Castleman's disease (MCD). The data were obtained from two phase 2, double-blind, placebo-controlled trials designed to test the efficacy of sirukumab in RA (N=176) or of siltuximab in MCD (N=65), and were analyzed post hoc to investigate the effects of these IL-6 antibodies on depressive symptoms. The SF-36 questionnaire items on depressed-mood and anhedonia were combined as the measure for depressive symptoms. The study participants were grouped by the presence/absence of prevalent depressed mood and anhedonia (PDMA, meaning either depressed mood or anhedonia was present at least 'most of the time' and the other at least 'some of the time' for four weeks) at baseline; 26.1% of the RA sample and 15.4% of the MCD sample met criteria for PDMA at baseline. Compared with placebo, sirukumab and siltuximab produced significantly greater improvements on depressive symptoms. To account for an effect on mood due to changes in RA or MCD, the analysis was (1) adjusted for symptom severities using DAS28-CRP for RA and MCDOS for MCD alone or together with bodily pain and physical functioning, and (2) performed within RA and MCD non-responders. Improvement in depressive symptoms remained significant in the treated group for both drugs. The significance over placebo was also observed in the siltuximab study. The improvement in depressive symptoms by sirukumab correlated positively with the baseline soluble IL-6 receptor levels. The data together suggest that the IL-6 antibodies improve depressive symptoms in patients with RA and MCD. Further studies are needed to elucidate to what extents the IL-6 antibodies improve depressive symptoms through improving primary disease dependent and independent mechanisms, especially in RA patients, and the brain mechanisms underlying depressive symptom improvements.
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Affiliation(s)
- Yu Sun
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Dai Wang
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Giacomo Salvadore
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Benjamin Hsu
- Immunology Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Mark Curran
- Immunology Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Corey Casper
- Fred Hutchison Cancer Research Center, United States
| | - Jessica Vermeulen
- Oncology Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Justine M Kent
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Jaskaran Singh
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Wayne C Drevets
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Gayle M Wittenberg
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States
| | - Guang Chen
- Neuroscience Therapeutic Areas, Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, United States.
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