Mental health concerns are common in the United States. In general, many dermatology patients have depression, anxiety, or some other psychiatric comorbidity at baseline. Historically, the mental health burden of psoriasis was especially striking. Approximately 20 years ago, patients with psoriasis reported reductions in quality of life that were comparable to that observed in patients with other major chronic medical diseases, such as cancer, heart disease, and diabetes. And, although therapies have become more effective over the years, psoriasis is still associated with mental health burden. 

How could the mental health burden of psoriasis be similar to that of diseases such as cancer or heart disease? Well, if you think of someone who has received a new cancer diagnosis, for instance, their friends and family often rally around them in support, providing them with both emotional support and day-to-day support such as bringing them meals. This usually does not happen for patients with psoriasis, whose unsightly lesions, scales, and odors may be repellent. When you have uncontrolled psoriasis, it can be socially disabling. This contributes to the mental health burden of the disease.

Psoriasis can affect many facets of life, including the clothing that patients wear. For example, patients may choose clothes that conceal their lesions. If they have scalp psoriasis, they may avoid dark-colored shirts and sweaters so that the scales do not appear as dandruff on their shoulders. Additionally, psoriasis in the intertriginous and genital areas is common and can have a big impact on patients psychosocially. It may be difficult for some people to even raise the issue of genital psoriasis with a physician, so asking about whether this is a concern for them can be important.

Screening for depression is needed in patients with psoriasis, just like it is in the setting of many other diseases. There might be visual cues from the patient during the visit, such as an avoidance of eye contact, a paucity of movement, or having low energy. This might prompt you to inquire about something innocuous such as their sleep habits; then you might expand your questions to explore the situation further, perhaps asking about their energy levels, their interest in activities, or any persistent sadness or crying. Although asking about suicidal ideation is key in determining whether a referral for an emergent mental health evaluation is needed, it may be best to ease into this question, starting with inquiries that are more benign (eg, questions about energy and sleep disturbance). 

Importantly, psoriasis treatment has changed remarkably over the last few decades. When I was first starting out in the field, our treatments were not as effective, and sometimes the most important things I did for a patient were a lot of handholding and encouraging them to join the National Psoriasis Foundation so that they could be a part of a community of people with psoriasis and learn how other people manage the psychosocial implications of the disease. This organization still does important work; however, today, with the effectiveness of newer systemic psoriasis treatments, the majority of patients with psoriasis can become clear or almost clear. The best way to address the stigma of psoriasis may be to clear up the disease. Having little or no visible psoriasis is certainly a good outcome for patients.