The risk of depression, suicidal ideation and suicide attempt in patients with psoriasis, psoriatic arthritis or ankylosing spondylitis

Association of psoriasis and periodontitis in the north Indian population

Background

Psoriasis is a chronic, non-communicable condition of the skin with an immune-mediated etiology. Periodontitis is a chronic inflammatory disease of the tooth-supporting tissues and is now recognized as an established risk factor for various systemic diseases. The present observational study aims to assess the prevalence of periodontitis and its related indices in individuals with psoriasis and to compare them with individuals without psoriasis. A cross-sectional case-control study was performed in a hospital setting, including 200 diagnosed cases of psoriasis and 200 age- and sex-matched healthy controls.

Methods

The case group included patients diagnosed with psoriasis (defined as ICD-10 L40.0-L40.9) by a trained dermatologist. Controls included age- and sex-matched healthy individuals. After history-taking, a detailed dermatological and periodontal examination was done for all the enrolled subjects. The results were statistically analyzed using SPSS software.

Results

The study group had a significantly higher mean GI, PI, PPD and CAL in comparison to the controls. Psoriasis patients had significantly greater scores for GI and PI (1.68 ± 0.61 and 1.57 ± 0.54, respectively) as compared to controls (1.48 ± 0.56 and 1.39 ± 0.60, respectively). Periodontitis was also found to be more prevalent among the cases. Stage II and Stage III periodontitis were found in 41.0 % of cases and 30.5 % of controls, while 12.5 % of cases and 6.0 % of controls had stage IV periodontitis. This difference was statistically significant.

Conclusion

An association between psoriasis and periodontitis was found in the present study, as the individuals with psoriasis had a higher severity and prevalence of periodontitis.

Prevalence and Impact of Unacceptable Symptom State among Patients with Psoriatic Arthritis: Results from the National Psoriasis Foundation's 2019 Annual Survey

The National Psoriasis Foundation surveyed a random, stratified sample of individuals with psoriatic disease in the United States to determine the prevalence of an unacceptable psoriatic arthritis (PsA) symptom state and its effect on depression and social participation. Acceptable and unacceptable levels of PsA were defined using established cutoff points (acceptable ≤4 vs unacceptable >4) on the Psoriatic Arthritis Impact of Disease 9. Psoriasis severity was defined by body surface area: mild < 3%, moderate-severe ≥ 3%. Depression was assessed utilizing the Patient Health Questionnaire 2. Social participation was assessed by the Patient Reported Outcome Information Measurement System Ability to Participate in Social Role and Activities-SF4a. The analysis cohort comprised 801 patients with PsA. Unacceptable disease activity level (Psoriatic Arthritis Impact of Disease >4) was reported by 59.6% of participants. After adjusting for age, sex, and psoriasis severity, individuals with likely depression (OR = 0.014, P < .001) and those with limited ability to participate in social roles and activities (OR = 0.05, P < .001) were less likely to experience acceptable levels of PsA activity. Ultimately, the results demonstrated that most United States patients with PsA have unacceptable levels of disease activity, which is associated with increased prevalence of depression and limitations in social participation.

Long-Term Safety of Risankizumab in Patients with Psoriatic Disease: A Comprehensive Analysis from Clinical Trials

INTRODUCTION

Risankizumab has demonstrated a favourable safety profile in patients with psoriatic disease (moderate-to-severe psoriasis [PsO] and psoriatic arthritis [PsA]). We evaluated the long-term safety of risankizumab in psoriatic disease.

METHODS

Long-term safety was evaluated by analysing data from 20 (phase 1-4) clinical trials for plaque PsO and four (phase 2-3) trials for PsA. Treatment-emergent adverse events (TEAEs) and AEs in areas of special interest were reported among patients receiving ≥ 1 dose of risankizumab. Exposure-adjusted event rates were presented as events (E) per 100 patient-years (PY).

RESULTS

The long-term safety data analyses included 3658 patients with PsO (13,329.3 PY) and 1542 patients with PsA (3803.0 PY). The median (range) treatment duration for patients with PsO and PsA was 4.1 (0.2-8.8) years and 2.8 (0.2-4.0) years, respectively. In the PsO population, rates of TEAEs, serious AEs and AEs leading to discontinuation were 145.5 E/100 PY, 7.4 E/100 PY and 1.9 E/100 PY, respectively; in the PsA population, these rates were 142.6 E/100 PY, 8.6 E/100 PY, and 1.8 E/100 PY, respectively. The rates of serious infections (excluding COVID-19-related infections) in the PsO and PsA populations were 1.2 and 1.4 E/100 PY, respectively. The rates of opportunistic infections (excluding tuberculosis and herpes zoster) were low (< 0.1 E/100 PY) in both populations. The rates of both nonmelanoma skin cancer (NMSC) and malignant tumours excluding NMSC were 0.6 and 0.5 E/100 PY in PsO and PsA, respectively, which are within the benchmarks of prior epidemiological studies. Adjudicated major cardiovascular event rates were 0.5 E/100 PY in PsO and 0.3 E/100 PY in PsA, which are within the epidemiologic reference benchmarks for both indications. No additional safety concerns were identified with this long-term exposure.

CONCLUSIONS

The results support the favourable safety profile of risankizumab for long-term treatment of psoriatic disease with no new safety concerns and similar safety profiles among both PsO and PsA populations.

Mental health outcomes in patients with moderate to severe psoriasis treated with bimekizumab: Analysis of phase 2/3 randomized trials

BACKGROUND

Patients with psoriasis have increased risk of suicidal ideation and behavior (SIB) and depression. Bimekizumab, a biologic that inhibits interleukin (IL)-17A and IL-17F, received Food and Drug Administration approval in 2023 for moderate to severe plaque psoriasis, following 2021 European Medicines Agency approval.

OBJECTIVE

To report SIB and depression in patients with moderate to severe psoriasis treated in bimekizumab clinical trials.

METHODS

Mental health changes, including neuropsychiatric events, were actively monitored across 9 bimekizumab clinical trials in psoriasis phase 2/3 trials. The patient-reported electronic Columbia-Suicide Severity Rating Scale (measuring SIB) and Patient Health Questionnaire-9 (measuring depression) were administered, monitored by an independent Neuropsychiatric Adjudication Committee.

RESULTS

Throughout 7166 patient-years (PY) of bimekizumab exposure, the adjudicated SIB rate was 0.13/100PY; SIB ranges for the general psoriasis population and patients receiving anti-IL-17A/anti-IL-23 therapies are 0.09 to 0.54/100PY and 0.09 to 0.19/100PY, respectively. At week 16, 92.9% vs 81.1% of bimekizumab- vs placebo-treated patients had no/minimal depression. Newonset positive electronic Columbia-Suicide Severity Rating Scale responses and mean Patient Health Questionnaire-9 scores were low for bimekizumab-treated patients.

LIMITATIONS

Patient exclusion for significant/severe prespecified SIB/depression history.

CONCLUSION

The long-term adjudicated SIB rate with bimekizumab was low and within ranges reported in the general psoriasis patient population and psoriasis patients treated with anti-IL-17A/anti-IL-23 biologics. Screening/monitoring questionnaires reported low SIB and depression levels.

Association between inflammatory joint disease and severe or treatment-resistant depression: population-based cohort and case-control studies in Sweden

OBJECTIVE

To investigate whether the association between depression and inflammatory joint disease (IJD; rheumatoid arthritis [RA], psoriatic arthritis [PsA], ankylosing spondylitis/spondyloarthropathies [AS], and juvenile idiopathic arthritis [JIA]) is affected by the severity or treatment-resistance of depression.

METHOD

Parallel cohort studies and case-control studies among 600,404 patients with a depressive episode identified in Swedish nationwide administrative registers. Prospective and retrospective risk for IJD in patients with depression was compared to matched population comparators, and the same associations were investigated in severe or treatment-resistant depression. Analyses were adjusted for comorbidities and sociodemographic covariates.

RESULTS

Patients with depression had an increased risk for later IJD compared to population comparators (adjusted hazard ratio (aHR) for any IJD 1.34 [95% CI 1.30-1.39]; for RA 1.27 [1.15-1.41]; PsA 1.45 [1.29-1.63]; AS 1.32 [1.15-1.52]). In case-control studies, patients with depression more frequently had a history of IJD compared to population controls (adjusted odds ratio (aOR) for any IJD 1.43 [1.37-1.50]; RA 1.39 [1.29-1.49]; PsA 1.59 [1.46-1.73]; AS 1.49 [1.36-1.64]; JIA 1.52 [1.35-1.71]). These associations were not significantly different for severe depression or TRD.

CONCLUSION

IJD and depression are bidirectionally associated, but this association does not seem to be influenced by the severity or treatment resistance of depression.

Association of self-reported arthritis with depression, anxiety, and comorbid depression/anxiety among the older Chinese adults: A cross-sectional study

BACKGROUND

Arthritis is relatively common among middle-aged and older people and is a significant public health problem. However, research on the relationship between arthritis and mental health in older populations is currently limited.

METHODS

Data were obtained from the Chinese Longitudinal Healthy Longevity Survey. The 10-item Center for Epidemiologic Studies Depression Scale and 7-item Generalized Anxiety Disorder Scale were used to evaluate depressive and anxiety symptoms. Arthritis status was self-reported. Linear and logistic regression analyses were conducted to assess the impact of arthritis on depression, anxiety, and comorbid depression/anxiety symptoms.

RESULTS

A total of 11,104 participants aged ≥65 years (mean age, 83.1 ± 11.1 years) were included in the analysis. We detected positive associations of arthritis with depression symptoms (adjusted odds ratio [OR]: 1.57, 95 % confidence interval [CI] 1.33 to 1.86), anxiety symptoms (adjusted OR: 1.48, 95 % CI: 1.15 to 1.90), and comorbid depression/anxiety symptoms (adjusted OR: 1.88, 95 % CI: 1.41 to 2.5) in the older adult population. Participants with arthritis had higher anxiety (adjusted linear regression coefficient: 0.43, 95 % CI: 0.24 to 0.63) and depression (adjusted linear regression coefficient: 0.87, 95 % CI: 0.57 to 1.14) scores compared with those without arthritis. In addition, there were no significant interaction effects between arthritis and participant characteristics on depression symptoms, anxiety symptoms, or comorbid depression/anxiety symptoms.

CONCLUSIONS

Arthritis was positively associated with depression symptoms, anxiety symptoms, and comorbid depression/anxiety symptoms among older adults. Further cohort studies are needed to validate these associations.

Psoriasis and its impact on close relatives and partners of patients - A cross-sectional questionnaire study

Background

Little is known about the exact impact of psoriasis on the disease burden of close relatives and partners of those affected by the disease.

Objectives

The aim of this single-centre cross-sectional study was to evaluate the quality of life in psoriasis patients and the impact of disease on partners and close relatives.

Methods

250 plaque-type psoriasis patients (58.4% males and 41.6% females) with mostly treatment-controlled disease (mean PASI of 1.7 and Dermatology Life Quality Index (DLQI) of 4.1) were recruited from the Psoriasis Registry Austria (PsoRA) and their close relatives and partners were invited to participate in the study. Patient Family Impact Score (PFIS) was calculated from the FamilyPso questionnaire data to establish categories of disease burden in close relatives and partners.

Results

Valid FamilyPso questionnaires were returned from 153 (61.2%) close relatives and partners. Correlation analysis revealed a significant association between PASI and DLQI (r = 0.512, p < 0.001), PASI and PFIS (r = 0.228, p = 0.006), and DLQI and PFIS (r = 0.210, p = 0.014). An at least small or larger impairment of life quality (DLQI ≥ 2) was observed in 46.7% of psoriasis patients, despite treatment. A small or larger disease burden was detected in nearly 78.7% of the male and 77.3% of the female relatives and partners quantified with categorized PFIS.

Conclusions

The study revealed a significant impact of patients' psoriasis on the disease burden of close relatives and partners, depending on the severity of PASI and extent of quality of life disruption in patients. The gender of the relatives and partners had no impact on the PFIS.

T cell-mediated skin-brain axis: Bridging the gap between psoriasis and psychiatric comorbidities

Psoriasis, a chronic inflammatory skin condition, is often accompanied by psychiatric comorbidities such as anxiety, depression, suicidal ideation, and other mental disorders. Psychological disorders may also play a role in the development and progression of psoriasis. The intricate interplay between the skin diseases and the psychiatric comorbidities is mediated by the 'skin-brain axis'. Understanding the mechanisms underlying psoriasis and psychiatric comorbidities can help improve the efficacy of treatment by breaking the vicious cycle of diseases. T cells and related cytokines play a key role in the pathogenesis of psoriasis and psychiatric diseases, and are crucial components of the 'skin-brain axis'. Apart from damaging the blood-brain barrier (BBB) directly, T cells and secreted cytokines could interact with the hypothalamic-pituitary-adrenal axis (HPA axis) and the sympathetic nervous system (SNS) to exacerbate skin diseases or mental disorders. However, few reviews have systematically summarized the roles and mechanisms of T cells in the interaction between psoriasis and psychiatric comorbidities. In this review, we discussed several key T cells and their roles in the 'skin-brain axis', with a focus on the mechanisms underlying the interplay between psoriasis and mental commodities, to provide data that might help develop effective strategies for the treatment of both psoriasis and psychiatric comorbidities.

Predicting comorbid mental health difficulties in people with autoimmune arthritis

Little is known about variables impacting the association between mental health difficulties and autoimmune conditions. This study investigates whether, age of onset, adverse childhood experiences (ACEs), and 'illness invisibility' predict comorbid mental health difficulties in people with autoimmune arthritis. Participants with autoimmune arthritis (N = 209) were recruited via social media platforms. Age of onset of arthritis and the temporal order of mental health difficulties (if applicable) were collected alongside a measure of personality and ACEs. A novel measure of illness invisibility was developed for this study. A cross-sectional mixed-subject design was utilised. 53.5% of the sample endorsed lifetime mental health difficulties. Logistic regression analyses revealed participants with a younger age of onset of arthritis had significantly higher odds of developing a mental health problem (OR 0.93, 95% CI 0.90-0.96). Independently, Illness Invisibility, endorsed by 89.9% of participants, significantly predicted postmorbid mental health difficulties (OR 1.08, 95% CI 1.01-1.19). Adverse Childhood Experiences were frequently endorsed within the sample with 37.8% reporting ≥ 3 cumulative ACEs. Every unit increase in ACEs increased the odds of having comorbid mental health difficulties (OR 1.27, 95% CI 1.09-1.47). Young people who are diagnosed with autoimmune arthritis maybe more likely to experience subsequent mental health difficulties. The 'invisibility' of their illness and exposure to ACEs also is associated with their risk for mental health complications. These findings highlight the importance of mental health screening for young people being investigated for arthritis and interdisciplinary care, especially for young people.

Brilaroxazine lipogel displays antipsoriatic activity in imiquimod-induced mouse model

BACKGROUND

Dopamine (D) and serotonin (5-HT) pathways contribute to psoriasis pathobiology. Disruptions incite increased inflammatory mediators, keratinocyte activation and deterioration, and worsening symptoms. Brilaroxazine (RP5063), which displays potent high binding affinity to D2/3/4 and 5-HT1A/2A/2B/7 receptors and a moderate affinity to serotonin transporter (SERT), may affect the underlying psoriasis pathology.

METHODS

An imiquimod-induced psoriatic mouse model (BALB/c) evaluated brilaroxazine's activity in a topical liposomal-aqueous gel (Lipogel) formulation. Two of the three groups (n = 6 per) underwent induction with 5% imiquimod, and one group received topical brilaroxazine Lipogel (Days 1-11). Assessments included (1) Psoriasis Area and Severity Index (PASI) scores (Days 1-12), skin histology for Baker score based on H&E stained tissue (Day 12), and serum blood collection for serum cytokine analysis (Day 12). One-way ANOVA followed by post hoc Dunnett's t-test evaluated significance (p < 0.05).

RESULTS

Imiquimod-induced animal Baker scores were higher versus Sham non-induced control's results (p < 0.001). Brilaroxazine Lipogel had significantly (p = 0.003) lower Baker scores versus the induced Psoriasis group. Brilaroxazine PASI scores were lower (p = 0.03) versus the induced Psoriasis group (Days 3-12), with the greatest effect in the last 3 days. The induced Psoriasis group showed higher Ki-67 and TGF-β levels versus non-induced Sham controls (p = 0.001). The brilaroxazine Lipogel group displayed lower levels of these cytokines versus the induced Psoriasis group, Ki-67 (p = 0.001) and TGF-β (p = 0.008), and no difference in TNF-α levels versus Sham non-induced controls.

CONCLUSION

Brilaroxazine Lipogel displayed significant activity in imiquimod-induced psoriatic animals, offering a novel therapeutic strategy.

Psychosocial Burden of Psoriasis: A Systematic Literature Review of Depression Among Patients with Psoriasis

Psoriasis is associated with various comorbidities with a notable psychosocial burden. This systematic literature review explores the burden of depression in patients with psoriasis, comparing it with that experienced by patients with other chronic medical conditions. Embase via Ovid, PubMed, and Cochrane Database of Systematic Reviews via Ovid were searched for peer-reviewed studies published in English between January 1, 2016 and December 6, 2021 that reported real-world evidence or observational studies involving at least 100 adults (age ≥ 18 years) with general (unspecified) or plaque psoriasis experiencing symptoms of depression (but not restricted to patients with a clinical diagnosis). Any report of depression or suicidality was eligible for inclusion. Systematic literature reviews reporting depression/suicidality in other chronic medical conditions were also included. Statistical analysis was not performed; the study was descriptive only. A total of 1744 records were identified, and after several defined screenings by two independent reviewers for publication year, relevance, and sample size, 82 publications were included. Psoriasis was significantly associated with depression. The prevalence of depression in patients with psoriasis ranged from 0.2% to 74.6%, with incidence from 4.83 to 91.9 per 1000 person-years. The prevalence of depression was generally higher among patients with more severe psoriasis than those with less severe disease (as determined by Psoriasis Area Severity Index [PASI] scoring system) and was more prevalent among women than men with psoriasis. Depression in psoriasis significantly reduced quality of life, including factors such as sexual dysfunction, sleep difficulties, subjective well-being, and addictions. Comorbid hypertension, hyperlipidemia, psoriatic arthritis, obesity, inflammatory bowel disease, diabetes, and statin use were all associated with increased depression risk in patients with psoriasis. This systematic literature review found that the burden of depression in psoriasis is no lower than in other chronic medical conditions. Greater awareness of the psychological impact of psoriasis would improve care and management, which should incorporate psychological interventions.

Insights into suicidal behavior among psoriatic arthritis patients: A systematic review and a genetic linkage disequilibrium analysis

OBJECTIVES

To systematically assess the magnitude of suicidal behavior among PsA patients and identify associated risk factors. Also identify common genes or coinherited single nucleotide polymorphisms (SNPs) implicated in suicidal behavior and PsA.

METHODS

Based on the PRISMA guidelines, we conducted a systematic literature review of the online databases PubMed/Medline, Web of Science, and EMBASE from inception to May 2022. Full-text original articles that describe suicidal behavior in PsA patients were eligible. All registered genome-wide association study (GWAS) data in the GWAS catalog database for PsA and psychiatric traits, such as suicidal behavior, and depression, were downloaded for further analysis.

RESULTS

A total of 48 articles were identified, and 6 were relevant to the study question .Among the 122,160 PsA patients, 700 had suicidal behavior (0,57%). The range of age in one study was between 30 and 49 years, and 64% of PsA patients with suicidal behavior were female. Among 13,899 PsA patients 74 had suicidal ideation (0.53%) and 125 suicide attempts occurred (0.9%). In two studies, among 17,383 patients, 13 complete suicides occurred (0.07%). A genetic haplotype on chromosomal region 6p21.1, spanning from 29,597,596 to 32,251,264 Mb, contains predisposing SNPs for PsA and depression. 6p21.1-6p21.3 is the chromosomal region containing the HLA genes of classes I, II and III.

CONCLUSION

Suicide behavior in PsA patients was associated with depression and other psychiatric comorbidities. Further evidence supports a genetic origin, at least partly. Awareness of these findings can help clinicians to recognize suicide behavior and prevent suicide attempts.

Polymorphisms in corticotrophin-releasing hormone-proopiomalanocortin (CRH-POMC) system genes: Neuroimmune contributions to psoriasis disease

BACKGROUND

Skin is a target organ and source of the corticotropin-releasing hormone-proopiomelanocortin (CRH-POMC) system, operating as a coordinator and executor of responses to stress. Environmental stress exacerbates and triggers inflammatory skin diseases through modifying the cellular components of the immune system supporting the importance of CRH-POMC system in the pathogenesis of psoriasis. The aim of this study was to analyse the association of CRH-POMC polymorphisms with psoriasis and evaluate transcript expression of lesional psoriatic and normal skin in RNA-seq data.

METHODS

Samples of 104 patients with psoriasis and 174 healthy controls were genotyped for 42 single nucleotide polymorphisms (SNPs) of CRH-POMC using Applied Biosystems SNPlex™ method. The transcript quantification was performed using Salmon software v1.3.0.

RESULTS

This study demonstrated the associations between melanocortin 1 receptor (MC1R) polymorphisms rs2228479, rs3212369, dopachrome tautomerase (DCT) polymorphisms rs7987802, rs2031526, rs9524501 and psoriasis in the Tatar population. Very strong association was evident for the SNP rs7987802 in the DCT gene (pc  = 5.95е-006) in psoriasis patients. Additionally, the haplotype analysis provided AT DCT (rs7992630 and rs7987802) and AGA MC1R (rs3212358, 2228479 and 885479) haplotypes significantly associated (pc  ˂ 0.05) with psoriasis in the Tatar population, supporting the involvement of DCT and MC1R to the psoriasis susceptibility. Moreover, MC1R-203 and DCT-201 expression levels were decreased in psoriasis lesional skin compared with healthy control skin.

CONCLUSIONS

This study is the first to identify genetic variants of the MC1R and DCT genes significantly associated with psoriasis in Tatar population. Our results support potential roles of CRH-POMC system genes and DCT in the pathogenesis of psoriasis.

Risk for incident suicidality among psoriasis patients: a systematic review and meta-analysis

Previous meta-analyses have produced conflicting conclusions about suicidality risk among psoriasis patients. We aimed to update the evidence on the risk for the whole continuum of incident suicidality in psoriasis patients. We performed an update systematic review and meta-analysis and searched CENTRAL, PubMed, and Embase from January 1, 2017 to August 14, 2021 for relevant new cohort studies and incorporated new studies into our previous systematic review. Random-effects model meta-analysis was used to obtain pooled hazard ratio (HR) with 95% confidence interval (CI). Subgroup analysis was conducted according to age and disease severity. A total of 12 studies were included in this meta-analysis. We detected no significant differences in the risk for incident completed suicide (HR 1.33, 95% CI 0.91-1.95), suicide attempt (HR 1.22, 95% CI 0.96-1.56), suicidal behavior (HR 1.08, 95% CI 0.98-1.19), and suicide ideation (HR 1.74, 95% CI 0.99-3.06) between psoriasis patients and non-psoriatic controls. In the subgroup analysis based on age, an increased risk for incident suicide ideation was observed in pediatric subgroup (HR 1.50, 95% CI 1.12-2.03). The updated evidence suggests no increased risk for whole continuum of incident suicidality spectrum in psoriasis patients but an increased risk for incident suicide ideation among pediatric psoriasis patients. Involving mental health professionals may be crucial in psoriasis management especially in young patients.

Epidemiology of mental health comorbidity in patients with psoriasis: An analysis of trends from 1986 to 2019

BACKGROUND

The prevalence of mental disorders such as depression, anxiety, and suicide has increased in patients with psoriasis, although no study has systematically analyzed the epidemiology worldwide.

OBJECTIVE

To explore the prevalence and incidence of psoriasis with comorbid mental disorders (i.e., depression, anxiety, and suicide).

METHODS

Five databases from establishment through May 2022 were searched. Stata SE 15.1 was used for the data analysis. Subgroup, meta-regression, and sensitivity analyses were used to evaluate the heterogeneity of pooled studies.

RESULTS

We evaluated 56 studies in our research. The prevalence of depression, anxiety, and suicide in adults with psoriasis was 20%, 21%, and 0.77%. Patients with psoriasis in North America had a higher prevalence of depression and suicide, whereas those in South America had a higher prevalence of anxiety. The incidence of depression, anxiety, and suicide was 42.1, 24.7, and 2.6 per 1000 person-years in adults with psoriasis, respectively.

LIMITATIONS

All of the included studies were published in Chinese and English, causing a degree of selection bias.

CONCLUSION

These findings demonstrate the incidence and prevalence of comorbid mental disorders in patients with psoriasis, which may raise awareness among physicians and patients regarding the mental problems associated with psoriasis.

Comorbidities in Psoriatic Arthritis: A Narrative Review

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.

Increased risk of suicidality in patients with psoriasis: A Nationwide cohort study in Korea

BACKGROUND

Psoriasis has a devastating psychological impact on patients' quality of life. However, the relationship between suicidality and psoriasis remains unclear.

OBJECTIVE

This study analysed and compared the risk of suicidality (suicidal ideation, suicide attempt and completed suicide) between patients with psoriasis and the general population.

METHODS

This nationwide, population-based, retrospective, cohort study analysed the Korean National Health Insurance Service claim data from 2005 to 2018.

RESULTS

The study included 348,439 patients with psoriasis aged over 18 years and with age- and sex-matched controls. The risk of suicidality was higher in the psoriasis group than in the control group [adjusted hazard ratio (aHR) 1.21; 95% confidence interval (CI), 1.18-1.24]. The aHR of suicidality was higher in the psoriatic arthritis group (aHR, 1.46; 95% CI, 1.39-1.54) than in the psoriasis-alone group (aHR, 1.17; 95% CI, 1.13-1.20). However, the severity of psoriasis and suicidality showed no correlation (mild psoriasis group: aHR, 1.22; 95% CI, 1.18-1.25; moderate-to-severe psoriasis group: aHR, 1.16; 95% CI, 1.10-1.23).

CONCLUSION

Patients with psoriasis have an increased risk of suicidality. In particular, the presence of arthritis in patients had a more significant effect on the risk of suicidality.

Killing all the birds with one drug - is oral roflumilast a novel treatment option for psoriasis?

Psoriasis is a common, chronic inflammatory skin disease associated with a large number of comorbidities. Though management of moderate-to-severe plaque psoriasis has greatly improved in recent years, patients with refractory disease or contraindications to available treatments still constitute therapeutic challenges. Oral roflumilast, a selective phosphodiesterase-4 (PDE-4) inhibitor, is approved for chronic obstructive pulmonary disease. Experimental studies have shown increased PDE-4 activity in psoriatic skin, and inhibition results in down-regulation of key inflammatory cytokines. Based on mode-of-action and available literature, we hypothesize that oral roflumilast is a future treatment for plaque psoriasis. Contrary to most existing psoriasis therapies, roflumilast has a favorable safety profile and holds the potential to improve not only skin manifestations but also commonly seen comorbidities. If efficacy and safety are confirmed in randomized settings, roflumilast can fill in a large unmet need and may represent a novel, relatively inexpensive, and convenient therapy positioned before biologics.

Patients with ankylosing spondylitis have high risk of irritable bowel syndrome. A long-term nationwide population-based cohort study

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory disease, might carry a high risk of irritable bowel syndrome (IBS) due to abnormal gut microbiota or inflammatory reaction.

METHODS

We conducted a 14-year retrospective cohort study based on Taiwan's National Health Insurance Research Database (NHIRD). A total of 4007 patients with newly diagnosed AS (outpatient visits≧3 times, or hospitalization≧1 time) and 988,084 non-AS comparisons were enrolled during 2000-2012. To ensure baseline comparability, the propensity score was matched by age, gender, comorbidities, and other possible confounders. The outcome was the incidence of IBS, followed up to the end of 2013. Cox proportional hazard model calculated adjusted hazard ratio (aHR) and the cumulative incidence of both groups was analyzed by the Kaplan-Meier method.

RESULT

After propensity score matching, baseline demographic characteristics were comparable between AS patients and the comparison group. The crude HR for IBS in the AS group was significantly higher 2.41 (95%C.I. =1.84-3.16) than comparison group. After adjusting for possible confounders, adjusted HR was 2.50 (95%C.I.=1.91-3.29). The cumulative incidence of IBS in AS was significantly higher than non-AS comparisons during the 14-year follow-up (P<0.001).

CONCLUSION

This nationwide population-based cohort study showed that patients with AS have higher risks of IBS than those of the non-AS comparison group.

Association of Psoriasis With Anxiety and Depression: A Case-Control Study in Chinese Patients

Background: Patients with psoriasis are prone to suffer from anxiety and depression during their lifetime. This study aimed to investigate the association of psoriasis with anxiety and depression in Chinese patients.

Methods: A case-control study in Chinese patients with psoriasis vulgaris and healthy controls was conducted. Clinical information based on patient-reported, clinical information, and reliable structured questionnaires were collected. Multivariable logistic regression was used to investigate the associations, in terms of adjusted odds ratios (AORs).

Results: We continuously selected 1,571 patients who were firstly diagnosed with psoriasis vulgaris, and 1,571 healthy controls, matched by age and sex. The risk of depression in the psoriasis vulgaris group was higher than that in the healthy controls (AOR = 1.30, P = 0.047), while no differences were found in the risk of anxiety between the two groups (AOR = 1.18, P = 0.381). Subgroup analysis by disease onsets showed that late-onset psoriasis (LOP) was significantly associated with a higher risk of anxiety (AOR = 1.47, P = 0.033) and depression symptoms (AOR = 1.85, P = 0.012) but not with early-onset psoriasis (EOP). Subgroup analysis by disease severity indicated that no difference was observed in the associations of mild psoriasis vulgaris, moderate-to-severe psoriasis vulgaris with anxiety and depression.

Conclusion: Patients with psoriasis vulgaris were more likely to develop depression compared with the general population. LOP patients were positively associated with anxiety and depression. We believe the screening of emotional disorders should be included in the daily management of psoriasis patients.

Depression and suicidality in patients with psoriasis and the role of psoriatic arthritis; a cross-sectional study in a tertiary setting

BACKGROUND

Depression is overrepresented in psoriasis. However, it is not clear whether the presence of psoriatic arthritis (PsA) independently increases patients' depressive burden. Furthermore, current evidence regarding suicidality risk of psoriasis populations is conflicting and the role of PsA on suicidality outcomes in psoriasis is unknown.

OBJECTIVES

(i) To test whether PsA is associated with depression and lifetime suicidal ideation among patients with psoriasis; (ii) to capture different suicidal phenomena in these patients; and (iii) to investigate whether suicidality and depressive symptom severity are associated with clinical markers of psoriasis severity and chronicity.

METHODS

A cross-sectional survey of tertiary patients (n=219, aged 18-65 years) with dermatologist-confirmed chronic plaque psoriasis, of whom 84 had rheumatologist-confirmed PsA, was undertaken. The Hospital Anxiety and Depression Scale and Sheehan-Suicidality Tracking Scale were used to assess depression and lifetime suicidality respectively.

RESULTS

PsA presence was associated with depression in patients with psoriasis, independently of other physical comorbidities (adjusted Odds Ratio 2.92, 95% Confidence Interval 1.53-5.68). Furthermore, patients with PsA experienced significantly higher levels of anhedonia and anxiety, after controlling for psychiatric history. 48.8% of all participants reported lifetime suicidal ideation with or without intent; 21.3% reported suicidal planning and 9.4% suicide attempts. Lifetime suicidality prevalence did not differ between patients with and without PsA. Depressive symptom severity and lifetime suicidality scores were not associated with objective measures of psoriasis severity or treatment group.

CONCLUSION

These data suggest that joint involvement in psoriasis is associated with higher depressive burden. There is a need for routine depression screening among patients with psoriasis, in particular when PsA is present. Anhedonia appears to be a particularly relevant symptom in the depression phenotype of this population. We did not find a statistically significant association between PsA and suicidality. Nevertheless, suicidality rates in tertiary patients with psoriasis appear to be higher than in the general population. Suicidality monitoring is recommended to help in reducing future psychiatric morbidity and mortality in patients with psoriasis.

Impact of Psoriasis and Hidradenitis Suppurativa in Pregnancy, a Systematic Review

Psoriasis and hidradenitis suppurativa (HS) are chronic inflammatory skin diseases that frequently develop in young women. The aim of this study is to evaluate how hidradenitis suppurativa and psoriasis impact women desiring to conceive, and their influence on fertility and gestation. A systematic review of articles dating from January 2015 to April 2021 was performed using the Scopus (Elsevier) database. The search terms were (psoriasis and (birth or pregnancy or fertility)) and ((hidradenitis suppurativa or acne inversa) and (birth or pregnancy or fertility)). The search was limited to human data. Systematic reviews, case reports, clinical practice guidelines, expert consensus and conference papers were excluded. The impact of HS on pregnancy includes an impaired desire for pregnancy, a decrease in fertility, the worsening of the disease during pregnancy and potential adverse events during pregnancy. Moreover, the pregnancy might imply a change on the treatment of HS. The impact of psoriasis on pregnancy includes a decrease in fertility, potential adverse events during pregnancy and an unpredictable evolution of the disease. Moreover, the pregnancy might imply a change on the treatment of psoriasis, although biologic therapies do not appear to increase the risk of adverse events. In conclusion, both HS and psoriasis have an impact on pregnancy. A decrease of fertility has been reported. Moreover, both diseases have an unpredictable evolution during pregnancy. Pregnant women who are under biologic therapy do not seem to have a higher rate of adverse events. Treatment of both conditions is usually halted during pregnancy since scientific evidence about their safety is not conclusive, or teratogenic risk has been proven.

Prevalence of Depressive Symptoms in Patients With Psoriatic Arthritis: Have Numbers Changed During the COVID-19 Pandemic?

This longitudinal analysis compares the prevalence of depressive symptoms in patients with psoriatic arthritis in the context of the COVID-19 pandemic. Data from a national patient register in Germany were analyzed regarding the Patient Health Questionnaire 2 (PHQ-2) to identify cases suspicious for depression at two time points, i.e., before and during the COVID-19 pandemic. Only patients with complete concurrent information on the Disease Activity in Psoriatic Arthritis Score (DAPSA) were included in the analysis. The frequency of depressive symptoms in psoriatic arthritis patients during the COVID-19 pandemic did not differ from the prevalence rates measured before. In addition, prevalence rates for depressive symptoms did not differ when stratifying the patient sample for DAPSA levels of disease activity measured before the pandemic. These results were confirmed further in a sensitivity analysis, limiting the second PHQ-2 assessment to lockdown periods only. However, longitudinal data on the prevalence of depressive symptoms in patients with rheumatic diseases, in general, and psoriatic arthritis, in particular, are scarce in the context of the COVID-19 pandemic. For a sensible comparison of prevalence rates for depressive symptoms in the future, underlying SARS-CoV-2 infection rates and resulting local healthcare disruptions need to be taken into account, besides the potential use of different depression screening tools to evaluate resulting numbers sensibly and draw corresponding conclusions for patient care.

Depression and Obesity in Patients With Psoriasis and Psoriatic Arthritis: Is IL-17-Mediated Immune Dysregulation the Connecting Link?

Patients with psoriasis are frequently obese and experience anxiety or suffer from depressive disorders. The immunopathogenesis of psoriasis and indeed psoriatic arthritis is largely based on the pivotal role of IL-17/IL-23 axis, to an extent that currently monoclonal antibodies selectively inhibiting IL-17 or IL-23 are routinely used for the treatment of psoriatic diseases. Emerging data, demonstrating a decisive role for IL-17 and IL-17 producing cell subsets, such as Th17 in the induction and progression of obesity and depression has led authors to suggest that psoriatic disease, obesity and anxiety/depression may indeed be interconnected manifestation of a state of immunedysregulation, the linked being IL-17 and its related cells. We discuss this hypothetical link in depth taking into account the beneficial effects anti-IL17 and anti-IL-17 receptor inhibitors in treating psoriatic disease and the on-going debate as to whether these biologics may exert a direct or indirect effect in ameliorating concomitant obesity and depressive disorders, which are frequently noted in the same patient.

Five-year maintenance of clinical response and health-related quality of life improvements in patients with moderate-to-severe psoriasis treated with guselkumab: results from VOYAGE 1 and VOYAGE 2

BACKGROUND

Psoriasis is a chronic disease requiring long-term therapy.

OBJECTIVES

Physician- and patient-reported outcomes were evaluated through week 252 in VOYAGE 1 and VOYAGE 2.

METHODS

In total, 1829 patients were randomized at baseline to receive guselkumab 100 mg every 8 weeks, placebo or adalimumab. Patients receiving placebo crossed over to guselkumab at week 16. Patients receiving adalimumab crossed over to guselkumab at week 52 in VOYAGE 1, and randomized withdrawal and retreatment occurred at weeks 28-76 in VOYAGE 2; all patients then received open-label guselkumab through week 252. Efficacy and health-related quality of life (HRQoL) endpoints were analysed through week 252. Safety was monitored through week 264.

RESULTS

The proportions of patients in the guselkumab group who achieved clinical responses at week 252 in VOYAGE 1 and VOYAGE 2, respectively, were 84·1% and 82·0% [≥ 90% improvement in Psoriasis Area and Severity Index (PASI)]; 82·4% and 85·0% [Investigator's Global Assessment (IGA) 0 or 1]; 52·7% and 53·0% (100% improvement in PASI) and 54·7% and 55·5% (IGA 0). HRQoL endpoints were achieved as follows: 72·7% and 71·1% of patients (Dermatology Life Quality Index 0 or 1: no effect on patient's life); 42·4% and 42·0% [Psoriasis Symptoms and Signs Diary (PSSD) symptom score = 0] and 33·0% and 31·0% (PSSD sign score = 0). As measured in VOYAGE 2 only, approximately 45% of patients achieved ≥ 5-point reduction in Short Form-36 physical and mental component scores, and 80% reported no anxiety or depression (Hospital Anxiety and Depression Scale scores < 8). Similar findings were reported for adalimumab crossovers. These effects were maintained from week 52 in VOYAGE 1 and week 100 in VOYAGE 2. No new safety signals were identified.

CONCLUSIONS

Guselkumab maintains high levels of clinical response and improvement in patient-reported outcomes through 5 years in patients with moderate-to-severe psoriasis.

Assessment of the effects of loneliness, perceived social support, and depression on medication adherence in patients with ankylosing spondylitis

PURPOSE

This study aims to investigate the effects of loneliness, perceived social support, and depression on medication adherence of patients with ankylosing spondylitis (AS).

DESIGN AND METHODS

This cross-sectional study was conducted with 119 AS patients. Data were collected using the Morisky-Green-Levine Medication Adherence Scale, the UCLA Loneliness Scale (ULS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Beck Depression Inventory (BDI).

FINDINGS

Nonadherent patients were younger (P = .033), scored higher on the ULS (P = .015), and BDI (P = .024) scales, and lower on the MSPSS scale (P = .039) and on family support (P = .002).

PRACTICAL IMPLICATIONS

The biopsychosocial aspects of patients with AS should be managed holistically to improve their medication adherence.

Suicidal risks with psoriasis and atopic dermatitis: Systematic review and meta-analysis

OBJECTIVE

Evidence of increased suicidal risk in association with psoriasis is growing, but findings concerning atopic dermatitis are inconsistent.

METHODS

We systematically reviewed reports of suicidal ideation, attempts, or suicides among subjects diagnosed with psoriasis or atopic dermatitis compared to healthy controls or persons with other illnesses. Reported rates of suicidal ideation and behavior were compared among the groups, using meta-analyses to compare suicidal rates with dermatologic patients versus controls, as well as between dermatological diagnoses.

RESULTS

Mean rates of suicidal ideation with psoriasis were 1.60-fold (13.9%/8.67%) above controls, and with atopic dermatitis, 1.84-fold higher (16.8%/9.12%); meta-analyses found similar differences: psoriasis (OR = 1.97 [CI: 1.26-3.08]; p = 0.003) and atopic dermatitis (OR = 2.62 [1.32-5.19]; p = 0.006). For suicidal acts, with psoriasis, mean rates versus controls were 2.51-fold higher (3.34%/1.33%), and 2.81-fold higher (5.03%/1.79%) with atopic dermatitis; meta-analyses found significantly more suicidal acts with psoriasis (OR = 1.42 [1.05-1.92]; p = 0.02) and a similar tendency with atopic dermatitis (OR = 1.53 [0.96-2.45]; p = 0.08).

CONCLUSIONS

The study findings support emerging evidence of increased risk of suicidal ideation and behavior with psoriasis and extend it to increased risk of suicidal ideation and a trend toward increased suicidal acts with atopic dermatitis.

[Depression and anxiety in patients with psoriatic arthritis: Prevalence and associated factors]

OBJECTIVE

To determine the prevalence of depression and anxiety in patients with psoriatic arthritis (PsA), to investigate whether there is a difference in the prevalence of depression and anxiety between PsA and rheumatoid arthritis (RA) patients and to identify associated risk factors for depression and anxiety in PsA patients.

METHODS

PsA and RA patients who visited Department of Rheumatology and Clinical Immunology in Peking University First Hospital from May 2018 to Sep 2019 were recruited. Self-rating anxiety scale and self-rating depression scale were surveyed and compared between PsA and RA patients. Demographics and clinical features including age, gender, disease duration, disease activity score, psoriasis area and severity index (PASI), and medical application were collected. Power Doppler and grey-scale ultrasound of joints, tenosynovitis and enthesis were performed. Multivariate Logistic regression was used to identify the factors associated with mood disorders and the odds ratio of depression and anxiety between the PsA and RA patients.

RESULTS

Among the 114 enrolled PsA patients, 37 (32.5%) had mood disorders, in which 36 (31.6%) with depression and 15 (13.2%) with anxiety. Compared with 201 RA patients, PsA patients showed greater odds for depression [adjusted OR (95%CI): 2.7 (1.1-6.4)]. Depression was more often observed in the PsA than in the RA patients (31.6% vs. 18.9%, P=0.011). The similar trend for anxiety was also observed, although the difference was insignificant (13.2% vs. 8.5%, P=0.185). Age (OR=0.95, P=0.008), psoriasis duration (OR=0.94, P=0.018), pain visual analogue scale (OR=1.47, P=0.011), PASI score (OR=1.07, P=0.007) and presence of ultrasound enthesitis (OR=4.13, P=0.009) were identified as factors associated with depression in the PsA patients. PASI score (OR=1.07, P=0.001) was identified as associated factor for anxiety in the PsA patients.

CONCLUSION

The prevalence of depression and anxiety is elevated in PsA patients. Depression is significantly more prevalent in PsA patients than in RA patients. Younger age, shorter psoriasis duration, worse pain and presence of ultrasound enthesitis are associated with depression, while severe psoriasis rash is associated with both depression and anxiety in PsA patients.

Risk of Depression in Patients With Psoriatic Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Previous systematic reviews have assessed the prevalence and odds ratio (OR) of depression for patients with psoriatic disease. Due to probable bidirectional effects, prevalence and prevalence ORs are difficult to interpret. No prior reviews have quantified the relative risk (RR) of depression following a diagnosis of psoriatic disease.

OBJECTIVE

To estimate the RR of depression in individuals with psoriasis and in psoriatic arthritis (PsA), clear-to-moderate psoriasis, and moderate-to-severe psoriasis subgroups.

METHODS

Observational studies investigating the risk of depression in adults with psoriatic disease were systematically searched for in Medline, EMBASE, PsycINFO, and CINAHL databases; 4989 unique references were screened. Studies that reported measures of incident depression in psoriasis patients were included. Thirty-one studies were included into the systematic review, of which 17 were meta-analyzed. Random effects models were employed to synthesize relevant data. Sources of heterogeneity were explored with subgroup analysis and meta-regression.

RESULTS

Seventeen studies were included in meta-analyses. The pooled RR of depression in psoriasis patients compared to nonpsoriasis controls was 1.48 (95% CI: 1.16-1.89). Heterogeneity was high (I² = 99.8%). Subgroup analysis and meta-regression did not indicate that PsA status or psoriasis severity (clear-to-mild, moderate-to-severe) were sources of heterogeneity. No evidence of publication bias was found.

CONCLUSIONS

This review demonstrates that the risk of depression is greater in patients with psoriasis and PsA. Future research should focus on developing strategies to address the mental health needs of this patient population for depression, including primary prevention, earlier detection, and treatment strategies.

Depression in patients with spondyloarthritis: prevalence, incidence, risk factors, mechanisms and management

Depression is a major neuropsychiatric disorder common in patients with rheumatological conditions including spondyloarthritis (SpA). It is associated with higher disease activity, functional impairment, poor treatment response and quality of life in patients with musculoskeletal disorders. Using ankylosing spondylitis (AS) and psoriatic arthritis (PsA) as examples, we have reviewed the evidence regarding the burden, risk factors, potential mechanisms and clinical management of depression in spondyloarthritis. The prevalence of depression is higher in patients with AS and PsA compared with the general population, with evidence of moderate/severe depression in about 15% of patients with AS or PsA. Mild depression is even more common and estimated to be present in about 40% of patients with AS. In addition to conventional risk factors such as stressful life events and socioeconomic deprivation, increased risk of depression in SpA may be associated with disease-related factors, such as disease activity, poor quality of life, fatigue, and sleep disturbances. Emerging evidence implicates inflammation in the aetiology of depression, which could also be a shared mechanism for depression and chronic inflammatory conditions such as AS and PsA. It is imperative for clinicians to actively assess and treat depression in SpA, as this could improve treatment adherence, quality of life, and overall long-term clinical and occupational outcomes. The use of validated tools can aid recognition and management of depression in rheumatology clinics. Management of depression in SpA, especially when to refer to specialist mental health services, are discussed.

The Risk of Systemic Diseases in Those with Psoriasis and Psoriatic Arthritis: From Mechanisms to Clinic

Psoriasis and psoriatic arthritis (PsA) have been recently considered as chronic systemic inflammatory disorders. Over the past decades, enormous evidence indicates that patients with psoriasis and PsA have a higher risk of developing various comorbidities including cardiovascular disease, metabolic disease, cancers, infections, autoimmune disease, and psychiatric diseases. However, reported risks of some comorbidities in those with psoriasis and PsA are somewhat different according to the research design. Moreover, pathomechanisms underlying comorbidities of those with psoriasis and PsA remain poorly elucidated. The purpose of this review is to provide the most updated comprehensive view of the risk of systemic comorbidities in those with psoriasis and PsA. Molecular mechanisms associated with the development of various comorbidities in those with psoriasis and PsA are also reviewed based on recent laboratory and clinical investigations. Identifying the risk of systemic comorbidities and its associated pathomechanisms in those with psoriasis and PsA could provide a sufficient basis to use a multi-disciplinary approach for treating patients with psoriasis and PsA.

Sex and Age Influence the Associated Risk of Depression in Patients with Psoriasis: A Retrospective Population Study Based on Diagnosis and Drug-Use

BACKGROUND

The reported prevalence of depression among individuals with psoriasis varies substantially, and the effect of gender on depression distribution has revealed conflicting results. In addition, using medication to identify cases is uncommon.

OBJECTIVE

To study the prevalence of pharmacologically treated depression among individuals with and without psoriasis in a Swedish population using ICD-10 codes and data from the Swedish Prescribed Drug Register.

METHODS

A retrospective case-control population-based study was performed including all living individuals (age ≥18 years) in Region Jönköping, southern Sweden (n = 273,536). ICD-10 codes for the diagnosis of psoriasis (L40.*) and depression (F32.* and F33.*), and data on pharmacological treatment from the Swedish Prescribed Drug Register, were extracted from electronic medical records between April 9, 2008 and January 1, 2016. The extraction date was January 1, 2016.

RESULTS

The risk of pharmacologically treated depression was increased in individuals with psoriasis (age- and sex-adjusted OR 1.55; CI 1.43-1.68); 21.1% of women with psoriasis received pharmacological treatment for depression during the study period compared to 14.2% in the control population. Prevalence figures for depression were significantly higher in women with psoriasis compared to men. The risk of suffering from depression was highest among male and female patients with psoriasis under the age of 31 years.

CONCLUSIONS

Depression is common among patients with psoriasis. The results of the current study underline the need for dermatologists to adopt a holistic approach, looking beyond the skin, when handling patients with psoriasis in every-day clinical practice.

Association between arthritis and depression risk: a prospective study and meta-analysis

OBJECTIVE

Our research aimed to prospectively evaluate the association between arthritis and depression among middle-aged and elderly Chinese and confirmed this association in other populations.

METHODS

Data from the China Health and Retirement Longitudinal Study were analyzed. Participants were enrolled in this study in 2011-2012 (Wave 1) and followed up in 2013-2014 (Wave 2) and 2015-2016 (Wave 3). Depression was defined as having a score equal to over 10 using the Chinese version of 10-item Center for Epidemiological Studies Depression scale. Arthritis was assessed by self-reported physician diagnosis in Wave 1. Cox proportional hazards regression models were fitted to evaluate prospective associations between baseline arthritis status and incident and persistent depression. Summary effect estimates were pooled from our findings and those reported in literature by applying random effects models.

RESULTS

The study included 7,386 participants aged 58.48 years (standard deviation, 9.59) for final analyses. Individuals with arthritis had a 35% higher risk (multivariable-adjusted hazard ratio [HR]: 1.35; 95% confidence interval [CI]: 1.23, 1.49) and 50% higher risk (HR: 1.50; 95% CI: 1.22, 1.84) of developing incident and persistent depression compared with those without arthritis. The meta-analysis of prospective studies confirmed increased risk of depression in individuals with arthritis (summary HR: 1.42, 95% CI, 1.34, 1.52).

LIMITATIONS

Depression was assessed by a screening tool and arthritis was assessed by self-reported physician diagnosis.

CONCLUSIONS

A positive relationship between arthritis and depression was noted in the middle-aged and elderly Chinese adults and other populations.

Acute mental health service use is increased in rheumatoid arthritis and ankylosing spondylitis: a population-based cohort study

Background

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with mental illness. Whether acute mental health (MH) service utilization (i.e. emergency visits or hospitalizations) is increased in RA or AS is not known.

Methods

Two population-based cohorts were created where individuals with RA (n = 53,240) or AS (n = 13,964) were each matched by age, sex, and year to unaffected comparators (2002-2016). Incidence rates per 1000 person-years (PY) were calculated for a first MH emergency department (ED) presentation or MH hospitalization. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated, adjusting for demographic, clinical, and health service use variables.

Results

Individuals with RA had higher rates of ED visits [6.59/1000 person-years (PY) versus 4.39/1000 PY in comparators] and hospitalizations for MH (3.11/1000 PY versus 1.80/1000 PY in comparators). Higher rates of ED visits (7.92/1000 PY versus 5.62/1000 PY in comparators) and hospitalizations (3.03/1000 PY versus 1.94/1000 PY in comparators) were also observed in AS. Overall, RA was associated with a 34% increased risk for MH hospitalization (HR 1.34, 95% CI 1.22-1.47) and AS was associated with a 36% increased risk of hospitalization (HR 1.36, 95% CI 1.12-1.63). The risk of ED presentation was attenuated, but remained significant, after adjustment in both RA (HR 1.08, 95% CI 1.01-1.15) and AS (HR 1.14, 95% CI 1.02-1.28).

Conclusions

RA and AS are both independently associated with a higher rate and risk of acute ED presentations and hospitalizations for mental health conditions. These findings underscore the need for routine evaluation of MH as part of the management of chronic inflammatory arthritis. Additional research is needed to identify the underlying individual characteristics, as well as system-level variation, which may explain these differences, and to help plan interventions to make MH service use more responsive to the needs of individuals living with RA and AS.

Rheumatic Conditions as Risk Factors for Self-Harm: A Retrospective Cohort Study

OBJECTIVE

To examine the risk of self-harm in rheumatic conditions.

METHODS

We conducted a retrospective cohort study using data from the Clinical Practice Research Datalink. Patients with ankylosing spondylitis, fibromyalgia, osteoarthritis, or rheumatoid arthritis were identified from 1990 to 2016 and matched to patients without these conditions. Incident self-harm was defined by medical record codes following a rheumatic diagnosis. Incidence rates (per 10,000 person-years) were reported for each condition, both overall and year-on-year (2000-2016). Cox regression analysis determined risk (hazard ratio [HR] and 95% confidence interval [95% CI]) of self-harm for each rheumatic cohort compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by age and sex. Due to nonproportionality over time, osteoarthritis was also stratified by disease duration (<1 year, ≥1 to <5 years, ≥5 to <10 years, and ≥10 years).

RESULTS

The incidence of self-harm was highest in patients with fibromyalgia (HR 25.12 [95% CI 22.45-28.11] per 10,000 person-years) and lowest for osteoarthritis (HR 6.48 [95% CI 6.20-6.76]). There was a crude association with each rheumatic condition and self-harm, except for ankylosing spondylitis. Although attenuated, these associations remained after adjustment for fibromyalgia (HR 2.06 [95% CI 1.60-2.65]), rheumatoid arthritis (HR 1.59 [95% CI 1.20-2.11]), and osteoarthritis (1 to <5 years HR 1.12 [95% CI 1.01-1.24]; ≥5 to <10 years HR 1.35 [95% CI 1.18-1.54]). Age and sex were weak effect modifiers for these associations.

CONCLUSION

Primary care patients with fibromyalgia, osteoarthritis, or rheumatoid arthritis (but not ankylosing spondylitis) are at increased risk of self-harm compared to people without these rheumatic conditions. Clinicians need to be aware of the potential for self-harm in patients with rheumatic conditions (particularly fibromyalgia), explore mood and risk with them, and offer appropriate support and management.

Depression in Psoriatic Arthritis: Dimensional Aspects and Link with Systemic Inflammation

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.

Risk for Suicidal Behavior Among Psoriasis Patients: A Nationwide Cohort Study

BACKGROUND

The link between psoriasis and suicidality remains elusive and understudied.

OBJECTIVE

The aim was to assess the risk of suicidal behavior in psoriasis patients.

METHODS

We used Taiwan's National Health Insurance Research Database to conduct a nationwide retrospective cohort study to examine the risk for suicidal behavior among psoriasis patients. We performed subgroup analyses based on the severity of psoriasis and psoriatic arthritis.

RESULTS

We included 169,909 psoriasis patients (including 13,959 with concomitant psoriatic arthritis and 155,950 with psoriasis alone) and 169,909 matched nonpsoriasis controls. Suicidal behavior occurred in 104 and 89 subjects in the psoriasis group and nonpsoriasis controls, respectively; we found no significantly increased risk for suicidal behavior among psoriasis patients when compared to nonpsoriasis controls [adjusted hazard ratio (HR) 1.17, 95% confidence interval (CI) 0.88‒1.55]. The subgroup analysis showed no significantly increased risk for suicidal behavior in both the severe psoriasis group (adjusted HR 0.92, 95% CI 0.51-1.64) and the mild psoriasis group (adjusted HR 1.26, 95% CI 0.91‒1.75) when compared to nonpsoriasis controls. Also, we found no significant increased risk for suicidal behavior in the group of psoriasis patients who also had psoriatic arthritis (adjusted HR 2.00, 95% CI 0.68‒5.85) and in the group of patients with psoriasis alone (adjusted HR 1.12, 95% CI 0.83‒1.50) when compared to nonpsoriasis controls.

CONCLUSION

In a Taiwanese setting, no link between psoriasis or psoriatic arthritis and suicidal behavior was detected.

Epidemiology of depression and anxiety in patients with psoriatic arthritis: A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of the prevalence, incidence, and medication treatment of depression and anxiety among patients with psoriatic arthritis (PsA).

METHODS

We searched Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL and PsycINFO for full-length studies that: utilized an observational design; included patients with PsA with/without a comparator group; evaluated depression and/or anxiety as an outcome, comorbidity, or predictor of a health outcome; and reported relevant estimates. We pooled estimates using random effects models.

RESULTS

Of 683 titles identified in our search, 18 studies met inclusion criteria. The pooled prevalence proportion for depression based on 11 studies was 17% (95% confidence interval [CI], 13% to 21%). In addition, a meta-analysis of four studies comparing the prevalence of depression in patients with PsA to those without PsA yielded a pooled odds ratio (OR) of 1.68 (95% CI, 1.37 to 2.08). The incidence of depression in PsA patients compared to the general population yielded a pooled incidence rate of 21.27 (95% CI, 16.28 to 26.27) per 1,000 person-years and a pooled incidence rate ratio of 1.44 (95% CI, 1.20 to 1.73). The pooled prevalence proportion of anxiety based on seven studies was 19% (95% CI, 11% to 29%) and a meta-analysis of two studies comparing the prevalence of anxiety in patients with PsA to those without PsA yielded a pooled OR of 1.49 (95% CI, 1.39 to 1.59). Only a small proportion of patients, between 2.4% and 13.5%, were reported to be taking antidepressant or antianxiety medications.

CONCLUSIONS

We identified substantial prevalence of depression and anxiety as well as elevated incidence of depression among patients with PsA. These findings should raise awareness of the importance of mental health care in this population.

Longitudinal associations between depressive symptoms and clinical factors in ankylosing spondylitis patients: analysis from an observational cohort

OBJECTIVES

Although cross-sectional studies have shown that ankylosing spondylitis-specific factors correlate with depressive symptom severity, the association of these factors over time is unresolved. We examined the demographic and clinical factors associated with longitudinal depressive symptom severity in AS patients.

METHODS

We analyzed sociodemographic, clinical, behavioral and medication data from 991 patients from the Prospective Study of Outcomes in Ankylosing spondylitis cohort, and measured depression severity with the Center for Epidemiological Studies Depression (CES-D) Scale administered at approximately 6-month visit intervals. Multivariable longitudinal negative binomial regression models were conducted using generalized estimating equation modeling to assess the demographic, clinical, and medication-related factors associated with depression severity by CES-D scores over time.

RESULTS

The median baseline CES-D score (possible range 0-60) was 10.0 (interquartile range = 5, 17). In longitudinal multivariable analyses, higher CES-D scores were associated with longitudinal smoking, greater functional impairment, greater disease activity, self-reported depression, and poor global health scores. Marital status (e.g., being married) was associated with lower CES-D. Adjusted mean CES-D scores in our model decreased over time, with a significant interaction between time and gender observed.

CONCLUSION

This study identified longitudinal clinical factors such as greater disease activity, greater functional impairment, and poor global health to be associated with longitudinal depression severity. These factors are potentially modifiable and may help manage depressive symptoms in AS.

The incidence of depression and anxiety in patients with ankylosing spondylitis: a systematic review and meta-analysis

Background

As awareness for the importance of mental health continues to expand in rheumatology, it is important to understand the epidemiology of psychiatric complications in ankylosing spondylitis (AS) with the ultimate goal of future prevention and improved quality of care. This study aims to review evidence on the incidence and determinants of depression and/or anxiety among patients with AS.

Methods

We searched Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL Complete, and PsycINFO for full-length observational studies that involved a sample or population of patients with AS and assessed depression and/or anxiety. Primary outcomes extracted were: 1) risk estimates for depression and/or anxiety (e.g., relative risk [RR]); and 2) determinants or factors identified as independent predictors of depression and/or anxiety using multivariable regression approaches and corresponding estimates (e.g., odds ratios [OR]). Where relevant, we pooled estimates using random effects models.

Results

Out of 783 titles from our search strategy, we reviewed 39 manuscripts. Four studies assessed the incidence of depression and meta-analyzing reported estimates from three of these studies yielded a pooled RR of 1.51 (95% CI 1.28 to 1.79). Differences in risk of depression among men and women with AS were inconclusive, suggesting need for further study. The incidence of anxiety was comparatively less studied with only one included study reporting a hazard ratio of 1.85 (95% CI 1.37 to 2.49). Education level was a key determinant, with lower levels associated with higher odds of depression (OR 6.65; 9% CI 1.36 to 32.51) and anxiety (OR 9.31; 9% CI 1.39 to 62.19) among AS patients.

Conclusions

Our systematic review and meta-analysis shows an increased risk of depression and anxiety among patients with AS. These findings suggest the importance of monitoring and care for psychiatric conditions in AS.

The risk of deliberate self-harm following a diagnosis of rheumatoid arthritis or ankylosing spondylitis: A population-based cohort study

Objective

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with mental illness. The risk of serious mental illness, including deliberate self-harm (DSH), in these conditions is not well known. We aimed to determine if RA or AS independently increases the risk for DSH.

Methods

We conducted retrospective, population-based cohort studies using administrative health data for the province of Ontario, Canada between April 1, 2002 and March 31, 2014. Individuals with incident RA (N = 53,240) or AS (N = 13,964) were separately matched 1:4 by age, sex, and year with comparators without RA or AS. The outcome was a first DSH attempt identified using emergency department data. We estimated hazard ratios (HR) and 95% confidence intervals (95% CI) for risk of DSH in RA and AS versus comparators, adjusting for demographic, clinical and health service utilization variables.

Results

Subjects with AS were significantly more likely to self-harm (crude incidence rate [IR] of 0.68/1,000 person years [PY] versus 0.32/1,000 PY in comparators), with an adjusted HR of 1.59 (95% CI 1.15 to 2.21). DSH was increased for RA subjects (IR 0.35/1,000 PY) versus comparators (IR 0.24/1,000 PY) only before (HR 1.43, 95% CI 1.16 to 1.74), but not after covariate adjustment (HR 1.07, 95% CI 0.86 to 1.33).

Conclusions

AS carries an increased risk for DSH but no such risk was observed in RA. Further evaluation of at-risk AS subjects is needed, including the longitudinal effects of disease and arthritis therapies on self-harm behaviour. This will inform whether specific risk-reduction strategies for DSH in inflammatory arthritis are needed.

Use of antidepressants and benzodiazepine-related hypnotics before and after initiation of TNF-α inhibitors or non-biological systemic treatment in patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis

Background

Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are autoimmune disorders associated with an increased risk for depression, anxiety and sleeping problems. The objective of this study was to analyze use of antidepressants and benzodiazepine-related hypnotics (BRH) in Sweden before and after first time treatment with anti-TNF and non-biological systemic (NBS) treatments among patients with the above diagnoses, and to correlate such use with that of randomly selected population controls.

Methods

Patients and dispensed drugs were identified in nationwide Swedish healthcare registers. Proportions of subjects filling prescriptions of antidepressants and BRH from 2 years before start of treatment (index-date), and 2 years after index date were assessed. Using the period -6 months to index-date as reference, prevalence rate ratios were computed for 6 months' intervals before and after index. For up to ten randomly selected population controls per patient, the same measures were calculated.

Results

A total of 6256 patients started anti-TNF treatment, and 13,241 NBS treatment. The mean age at index was 52.0 for the anti-TNF group and 56.1 for NBS. Use of antidepressants and BRH was similar in both treatment groups (10.4-12.8%), significantly more common than in the controls (6.6 to 7.6%). For all patients, proportions filling prescriptions for antidepressants and BRH decreased directly or soon after the index; no such changes were seen in the controls, who all showed a slow but steady increase in use over time. Starters of anti-TNF treatment did not show clearer decreases in use of psychotropics than those initiating NBS.

Conclusions

Decreased rates of dispensed psychotropic drugs after the time of anti-TNF and NBS treatment initiation were seen among patients with autoimmune disorders but not population controls. This may correspond to treatment effects of anti-TNF and NBS also on psychiatric symptoms among these patients.

Bidirectional association between psoriasis and depression: Two longitudinal follow-up studies using a national sample cohort

BACKGROUND

Few studies have investigated the bidirectional association between psoriasis and depression. The aim of our study was to identify the association between psoriasis and depression.

METHODS

Data collected by the Korean Health Insurance Review and Assessment from 2002 to 2013 were used. In study I, psoriasis patients (n = 10,932) were matched 1:4 with control I group participants. In study II, depression patients (n = 60,383) were matched 1:4 with control II group participants. Matching was performed for age, sex, income, and region of residence. The stratified Cox-proportional hazard model was used to calculate the hazard ratio (HR) with crude and adjusted models.

RESULTS

In study I, the adjusted HR for depression was 1.13 (95% confidence interval (CI) = 1.03-1.24) in the psoriasis group compared to the control I group. In study II, the adjusted HR for depression was 1.11 (95% CI = 1.00-1.22) in the depression group compared to the control II group. In the subgroup analyses, the adjusted HRs for depression were 1.24 (95% CI = 1.00 - 1.53) in females aged < 40 years and 1.31 (95% CI = 1.04 - 1.66) in males aged ≥ 60 years. In the subgroup analyses from study II, the adjusted HRs for psoriasis were 1.56 (95% CI = 1.15 - 2.12) in males aged < 40 years and 1.35 (95% CI = 1.04 - 1.75) in males aged ≥ 60 years.

CONCLUSIONS

We suggest that psoriasis and depression might have a bidirectional association.

Systematic review of mental health comorbidities in psoriatic arthritis

OBJECTIVE

In this systematic review and meta-analysis of psoriatic arthritis (PsA) studies, we pooled data from existing literature to (1) estimate the prevalence of mental health disorders in PsA patients and (2) compare disease activity in PsA patients with and without these comorbidities.

METHOD

We searched PubMED, Web of Science, Scopus, PsycINFO and the Cochrane Library using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Where possible, meta-analysis was performed using random effects model. Prevalence estimates were pooled according to the severity of mental health disorders.

RESULTS

A total of 24 studies, amounting to 31,227 PsA patients, were included for review. Anxiety and depression were the only consistently reported mental health disorders, defined using a range of screening criteria/thresholds. Anxiety prevalence ranged from 4 to 61% with a pooled estimate of 33% (95%CI 17 to 53%) having at least mild anxiety and 21% (95%CI 14 to 29%) at least moderate. Depression prevalence ranged from 5 to 51%, with 20% (95%CI 8 to 35%) having at least mild and 14% (95%CI 8 to 21%) at least moderate. Only two studies compared disease activity according to the presence of mental health comorbidities; both reported higher disease activity and pain among those with comorbid anxiety and depression.

CONCLUSIONS

Anxiety and depression are highly prevalent among PsA patients. Studies of other mental health disorders were scarce. More studies are needed on the impact of these comorbidities on disease activity and long-term outcomes.Key Points• One in three patients with psoriatic arthritis has at least mild anxiety, while 1 in 5 reported at least mild depression.• PsA patients with anxiety and/or depression reported greater disease activity.• More research is needed on other mental health comorbidities, particularly sleep, suicide/self-harm and substance misuse.

Comparison of Hospital Anxiety and Depression Scale (HADS) and Zung Self-Rating Anxiety/Depression Scale (SAS/SDS) in Evaluating Anxiety and Depression in Patients with Psoriatic Arthritis

BACKGROUND

This study aimed to compare the Hospital Anxiety and Depression Scale (HADS) and the Zung Self-Rating Anxiety/Depression Scale (SAS/SDS) in evaluating anxiety and depression in psoriatic arthritis (PsA) patients.

METHODS

A total of 70 PsA patients were enrolled. Demographic and clinical characteristics were collected after enrollment. HADS-A and SAS were used to evaluate the anxiety of PsA patients, while HADS-D and SDS were used to evaluate the depression of PsA patients.

RESULTS

Similar results were observed in detecting the rate of anxiety by HADS-A and SAS (27.1 vs. 21.4%, p = 0.424), and there was no difference in classifying the severity of anxiety by HADS-A and SAS (p = 0.347). The Spearman test also disclosed that HADS-A score was positively associated with SAS score (p <0.001). The rates of depression were similar by HADS-D and SDS (27.1 vs. 40.0%; p = 0.108). However, different results were observed in grading the severity of anxiety by HADS-D and SDS (p = 0.009), and no correlation was observed between HADS-D and SDS scores (p = 0.138). The consumption of time for HADS assessment was shorter than that for SAS/SDS assessment (p < 0.001). In addition, a positive correlation of HADS-A score with patients' global assessment (PGA) (p = 0.022) and fatigue scores (p = 0.028) was discovered, and HADS-D score was positively associated with PGA score (p = 0.019). SAS or SDS score presented less correlation with clinical features of PsA patients, which illuminated that only SAS score was positively associated with duration of psoriasis (p = 0.030).

CONCLUSION

HADS seems to be a better option for anxiety and depression assessment than SAS/SDS in PsA patients.

Defining Depression and Anxiety in Individuals With Rheumatic Diseases Using Administrative Health Databases: A Systematic Review

OBJECTIVE

To conduct a systematic review to describe how administrative health databases have been used to study depression and anxiety in patients with rheumatic diseases and to synthesize the case definitions that have been applied.

METHODS

Search strategies to identify articles evaluating depression and anxiety among individuals with rheumatic diseases were employed in Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, and PsycINFO. Studies included were those using administrative health data and reporting case definitions for depression and anxiety using International Classification of Diseases (ICD) codes. We extracted information on study design and objectives, administrative health database, specific data sources (e.g., inpatient, pharmacy records), ICD codes, operational definitions, and validity of case definitions.

RESULTS

Of the 36 studies included in this review, all studies assessed depression, and 13 studies (36.1%) evaluated anxiety. A number of specific ICD-9/10 codes were consistently applied to identify depression and anxiety, but the overall combination of ICD codes and operational definitions varied across studies. Twenty-four studies reported operational definitions, and 19 of these studies (79.2%) combined claims from more than 1 type of administrative data source (e.g., inpatient, outpatient). Validated case definitions were used by 6 studies (16.7%), with sensitivity estimates for depression and anxiety case definitions ranging from 33% to 74% and 42% to 76%, respectively.

CONCLUSION

We identified numerous case definitions used to evaluate depression and anxiety among individuals with rheumatic diseases within administrative health databases. Recommendations include using case definitions with demonstrated validity as well as operationalizing case definitions within multiple data sources.

Models of human psoriasis: Zebrafish the newly appointed player

Psoriasis is a human chronic, immune disease with severe cutaneous and systemic manifestations. Its prevalence, among the world population, highly varies with ethnicity and geography, but not sex from remarkable low levels in Asia to 2.3% in Spain, or an impressive 11.5% in Norway. The pathogenesis of psoriasis derives from complex genetic and environmental interactions, which creates aberrant crosstalk between keratinocytes and variated immune cell, resulting in open amplified inflammatory and pro-proliferative circuits. Both, innate and adaptive immune systems are known to be involved in the response at the cellular and humoral levels. Nevertheless, the exact molecular mechanisms are still under debate. Therefore, discovering useful therapeutic targets to stretch the molecular gaps in psoriasis pathogenesis and its associated comorbidities is still mandatory. So far, some mutagenic or pharmacological studies in vitro or using comparative vertebrate models have provided critical molecular insights and directed the human research. Although highly feasible in rodents, the versatile physiology, genetic similarity to humans and outstanding molecular toolbox available, suggest that elaborate forward genetic screenings are far easier to be conducted using the zebrafish model. Thus, in this review, we intend to briefly overview psoriasis and revise in a digested fashion the preclinical research models available, emphasizing the zebrafish as a powerful tool in the study of immune effectors on the same, and how it supports the discovering of new therapies that may help in controlling this widespread disease around the globe.