Best Antidepressant for Patients with Psoriasis
Selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line antidepressants for patients with psoriasis, based on their potential dual benefit of treating depression while possibly reducing cardiovascular risk, which is elevated in this population. 1
Rationale for SSRIs
The guidelines specifically mention SSRIs as having "suggestive evidence" for reducing cardiac events, which is particularly relevant given that psoriasis patients face increased cardiovascular disease risk. 1 While the evidence for cardiovascular protection is not yet firmly established, this potential benefit makes SSRIs the most logical choice when firm evidence for this cardiovascular benefit is lacking. 1
Key Clinical Considerations
Depression Prevalence in Psoriasis
- Depression affects 24-60% of psoriasis patients, representing a substantial comorbidity burden. 1
- Nearly 10% of psoriasis patients report wishing to be dead, and 5% report active suicidal ideation, making depression screening and treatment critical. 1
- Antidepressant use is significantly increased in psoriasis patients compared to controls, with a hazard ratio of 1.55. 2
The Inflammatory Connection
- Depression in psoriasis is not purely psychological but is driven by metabolic inflammation involving IL-23, IL-17, TNF, IL-6, and IL-8, which cause neuroinflammation. 3
- This inflammatory pattern creates a biological link between psoriasis and depression, suggesting that treating the underlying inflammation may help both conditions. 3, 4
Treatment Algorithm
Step 1: Screen for Depression
- Simply ask about depressed mood and anhedonia, as this approach detects the majority of depressed patients and may perform better than formal screening instruments. 1
- Patients showing signs or symptoms of depression should be referred to an appropriate healthcare professional for assessment. 1
Step 2: Initiate SSRI Therapy
- Start an SSRI as first-line antidepressant therapy given the cardiovascular considerations in psoriasis patients. 1
- The specific SSRI choice should follow standard psychiatric prescribing practices, as no particular SSRI has been shown superior in this population.
Step 3: Optimize Psoriasis Treatment Concurrently
- Aggressive treatment of psoriasis itself can significantly improve depressive symptoms, as demonstrated with biologics like etanercept and adalimumab. 1
- Biologic therapy showed the greatest impact on depression symptoms (incidence rate 3.01/100 patient-years), followed by conventional systemic therapy (5.7/100 patient-years) and phototherapy (5.85/100 patient-years). 1
- TNF, IL-17, and IL-23 inhibitors can improve depression/depressive symptoms by addressing the underlying inflammatory pathways. 3
Step 4: Address Cardiovascular Risk Factors
- Implement lifestyle modifications including smoking cessation, weight loss to achieve BMI <25, and exercise 30 minutes three times weekly. 1
- Monitor and modify cholesterol levels to recommended ranges, as depression treatment may help reduce cardiovascular events. 1
Important Caveats
The psychological distress in psoriasis patients is not correlated with clinical symptom intensity, meaning even patients with mild skin disease may have severe depression. 5 This underscores the importance of screening all psoriasis patients regardless of disease severity.
Younger patients and those with more severe disease are at highest risk for depression and suicidality, requiring particularly vigilant monitoring. 6
There is significant undertreatment of depression in psoriasis patients, with dermatologists often failing to identify or address psychological distress. 5 Proactive screening and referral are essential.
The period after initiating antipsoriatic treatment is characterized by a further increase in antidepressant drug use (HR 1.07), suggesting that starting psoriasis therapy may unmask or temporarily worsen depressive symptoms. 2