Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Management of psoriasis must include psychosocial interventions
- Peter Byrne (13 June 2007)
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Management of psoriasis must include psychosocial interventions- Authors Reply
- Sophie C Weatherhead, Stephen C Robson, Nick J Reynolds (17 June 2007)
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Management of psoriasis must include psychosocial interventions
- Peter Byrne (18 June 2007)
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Cytokine profile in psoriasis
- laxmisha chandrashekar (15 August 2007)
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Cytokine profile in psoriasis - authors reply
- Sophie C Weatherhead, Stephen C Robson, Nick J Reynolds (17 August 2007)
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Peter Byrne, consultant psychiatrist West London Mental Health Trust, UB1 3EU
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Weatherhead and colleagues (1) have provided a useful account of the pharmacology of psoriasis around pregnancy, warning of the dangers of some topical agents with specific advice about cessation of systemic known teratogens. While I accept that there are no studies of the effects of pregnancy on depression in people with psoriasis, they neglect to cite a large literature (2-5) defining high levels of depression in psoriasis patients. Depression is a preventable and treatable disorder – even in pregnancy – and clinicians will serve psoriasis patients well in identifying its symptoms. It is worth noting that clinically-relevant levels of anxiety occur in higher proportions of patients than those who are depressed (2-3, 5-6). Fried et al (6) confirm both higher anxiety levels and good correlation between perceptions that stress made their psoriasis worse and actual relapses of skin lesions. Pregnancy is usually a happy life event, but it may increase distress in women with skin or other chronic medical disorders. All physicians should look for and help remediate psychosocial disabilities as well as physical ones. 1. Weatherhead, S, Robson SC and Reynolds NJ. Management of psoriasis in pregnancy. BMJ 2007; 334: 1218-19. 2. Scharloo M, Kaptein AA, Weinman J, Bergman W, Vermeer BJ, Rooijmans H- GM. Patients' illness perceptions and coping as predictors of functional status in psoriasis: a 1-year follow-up. British Journal of Dermatology 2000; 142:899-907. 3. Richards HL, Fortune DG, Griffiths CE, Main CJ. The contributions of perceptions of stigmatisation to disability in patients with psoriasis. Journal of Psychosomatic Research 2001; 11:11-15. 4. Akay A, Pekcanlar A, Bozdag KE, Altintas L, Karaman A. Assessment of depression in subjects with psoriasis vulgaris and lichen planus. Journal of the European Academy of Dermatology and Venereology 2002; 16:347-352. 5. Fortune DG, Richards HL, Griffiths CE, Main CJ. Psychological stress, distress and disability in pateints with psoriasis. British Journal of Clinical Psychology 2002; 41:157-174. 6. Fried RG, Friedman S, Paradis C et al. Trivial or terrible? The psychosocial impact of psoriasis. International Journal of Dermatology 1995; 34:101-105. Competing interests: None declared |
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Sophie C Weatherhead, Wellcome Research Training Fellow University of Newcastle, NE1 4LP, Stephen C Robson, Nick J Reynolds
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Dr Peter Byrne (BMJ rapid response, 13th June 2007) highlights the important problem of depression associated with psoriasis, and we agree that this is an integral part of overall management of these patients. However, it was beyond the scope of our article to discuss such problems generally related to psoriasis, and we set out to identify specific issues related to pregnancy. As Dr Byrne points out there is no evidence of this being more of a problem for the pregnant patient with psoriasis, although it should be noted that depression has been found in nearly a third of screened psoriatic patients in a recent study.1 Furthermore a link has been suggested between treating depression with paroxetine and improvement of psoriasis.2 Manufacturers of SSRIs only advise using these drugs in pregnancy if the potential benefit outweighs the risk, and the decision to treat during pregnancy should therefore be decided on a case by case basis, and where possible this should be addressed prior to conception. The psychological effects of chronic diseases such as psoriasis, are a major issue affecting morbidity and are certainly worthy of a separate review. 1. Schmitt J, Ford DE. Understanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health-related quality of life and depressive symptoms in patients with psoriasis - a structural equations modeling approach. Gen Hosp Psychiatry 2007;29(2):134-40. 2. Luis Blay S. Depression and psoriasis comorbidity. Treatment with paroxetine: two case reports. Ann Clin Psychiatry 2006;18(4):271-2. Competing interests: The department has received financial income and support from Stiefel Laboratories, Leo Pharmaceuticals, Schering Plough, and Merck Serono. |
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Peter Byrne, consultant psychiatrist West London Mental Health Trust, UB1 3EU
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While I appreciate the authors’ speedy reply to my rapid response to their review (1), and their acknowledgement that one third of psoriasis patients screen positive for depression (2), they have missed my point in relation to undiagnosed anxiety disorders in this group. Further, I disagree with their assertion that the next treatment consideration here should be the prescription of antidepressants. Specifically, paroxetine is a short-acting SSRI likely to be problematic in people with chronic medical illnesses – in whom side effects and adherence are likely – along with wider concerns about medication in pregnancy (1) and paroxetine’s links with suicide (http://www.bmj.com/cgi/eletters/330/7488/385). My use of the term “psychosocial” applies not just to pathogenesis, but also to the need for psychosocial treatments (education, support, problem solving therapy, cognitive behavioural interventions etc.). Though studies tend to be small and of short duration, there is good evidence to support structured non-medication interventions in people with psoriasis (3). Separate reviews of psychosocial treatments in psoriasis (and other medical conditions) perpetuate clinicians’ marginalisation of their use. 1. Weatherhead, S, Robson SC and Reynolds NJ. Management of psoriasis in pregnancy. BMJ 2007; 334: 1218-19. 2. Schmitt J, Ford DE. Understanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health- related quality of life and depressive symptoms in patients with psoriasis - a structural equations modeling approach. Gen Hosp Psychiatry 2007;29(2):134-40. 3. Fortune DG, Richards HL, Kirby, B et al. A cognitive-behavioural symptom management programme as adjunct in psoriasis therapy. British Journal of Dermatology 2002; 146: 458-65. Competing interests: None declared |
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laxmisha chandrashekar, lecturer Christian medical college,Vellore
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Psoriasis vulgaris has a predominant TH1 profile and not TH2 as mentioned in the text. This mistake needs to be rectified. Competing interests: None declared |
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Sophie C Weatherhead, Wellcome Research Training Fellow Newcastle-upon-Tyne NE1, Stephen C Robson, Nick J Reynolds
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We are grateful to Dr Chandrashekar for pointing out this typographical error. Psoriasis does of course cause a bias towards the T helper 1 profile, and pregnancy biases towards the T helper 2 profile. We apologise for any confusion his may have caused. A correction will follow. Competing interests: Authors of original article |
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