Recent research suggests that the psychological effects of psoriasis are more complex than a simple response to living with a skin disease associated with stigma. Psychiatric conditions such as depression, anxiety, and suicidal ideation are now understood as comorbidities of psoriasis. This roundtable discussion brings together expert clinicians to discuss the psychological comorbidities of psoriasis. They also discuss how clinicians treating patients with psoriasis can screen for these comorbidities. The goal is to provide the best possible outcome for the whole patient.
This certified CME activity is designed for dermatologists, physician assistants, and nurse practitioners that treat patients with psoriasis.
Supported from an educational grant from Ortho Dermatologics, Inc.
Upon completion of this activity, the participant should be able to:
Evolve Medical Education LLC (Evolve) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit Designation Statement
Evolve designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The following faculty/staff members have the following financial relationships with commercial interests:
Jerry Bagel, MD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Grant/Research Support: AbbVie; Boehringer-Ingelheim, Celgene, Eli-Lilly, Janssen, and Novartis. Speaker’s Bureau: AbbVie; Celgene, Eli-Lilly, Janssen, and Novartis.
Richard G. Fried, MD, PhD, has no financial relationships with commercial interests.
Leon Kircik, MD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Advisory Board: Aclaris, Allergan, Inc., Almirall, Anacor Pharmaceuticals, Biogen-Idec, Colbar, Celgene, Cipher, Connetics Corporation, EOS, Exeltis, Ferndale Laboratories, Inc., Galderma Laboratories, LP, Genentech, Inc., Intendis, Innocutis, Isdin, Johnson & Johnson, Nano Bio, OrthoNeutrogena, Promius, Quinnova, SkinMedica, Inc., Stiefel Laboratories, Inc., Sun Pharma, Valeant Pharmaceuticals Intl/Ortho Dermatologics, and Warner-Chilcott. Consultant: Allergan, Inc., Almirall, Amgen, Inc., Anacor Pharmaceuticals, Colbar, Cipher, CollaGenex, Connetics Corporation, Exeltis, Galderma Laboratories, LP, Genentech, Inc., Intendis, Isdin, Johnson & Johnson, Laboratory Skin Care Inc., Leo, Medical International Technologies, Merck, Merz, Novartis AG, OrthoNeutrogena, Promius, PuraCap, SkinMedica, Inc., Stiefel Laboratories, Inc., Sun Pharma, Taro, UCB, Valeant Pharmaceuticals Intl/Ortho Dermatologics, and ZAGE. Grant/Research Support: Acambis, Allergan, Inc., Amgen, Inc., Anacor Pharmaceuticals, Astellas Pharma US, Inc., Asubio, Berlex Laboratories, Biolife, Biopelle, Boehringer-Ingelheim, Breckinridge Pharma, Celgene, Centocor, Inc., Cellceutix, Coherus, CollaGenex, Combinatrix, Connetics Corporation, Coria, Dermavant, Dermira, Dow Pharmaceutical Sciences, Inc., Dusa, Eli Lilly, Exeltis, Ferndale Laboratories, Inc., Galderma Laboratories, LP, Genentech, Inc., GlaxoSmithKline, PLC, Health Point, LTD, Idera, Intendis, Johnson & Johnson, Leo, L’Oréal, 3M, Maruho, Merck, Medicis Pharmaceutical Corp., Nano Bio, Novartis AG, Noven Pharmaceuticals, Nucryst Pharmaceuticals Corp, Obagi, Onset, OrthoNeutrogena, Promius, QLT, Inc., PharmaDerm, Pfizer, Quinnova, Quatrix, SkinMedica, Inc., Stiefel Laboratories, Inc., Sun Pharma, TolerRx, UCB, Valeant Pharmaceuticals Intl/Ortho Dermatologics, Warner-Chilcott, and XenoPort. Speaker’s Bureau: Abbott Laboratories, Allergan, Inc., Amgen, Inc., Assos Pharma, Astellas Pharma US, Inc., Cipher, CollaGenex, Connetics Corporation, Dermik Laboratories, Embil Pharmaceuticals, Exeltis, Galderma Laboratories, LP, Genentech, Inc., Innocutis, Innovail, Johnson & Johnson, Leo, L’Oréal, 3M, Onset, OrthoNeutrogena, PediaPharma, PharmaDerm, Serono, SkinMedica, Inc., Stiefel Laboratories, Inc., Sun Pharma, Taro, Triax, UCB, Valeant Pharmaceuticals Intl/Ortho Dermatologics, and Warner-Chilcott. Stock/Shareholder: Johnson & Johnson.
Jashin J. Wu, M.D., has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant: AbbVie, Almirall, Amgen, Bristol-Myers Squibb, Celgene, Dermira, Dr. Reddy’s Laboratories, Eli Lilly, Janssen, LEO Pharma, Novartis, Ortho Dermatologics, Promius Pharma, Regeneron, Sun Pharmaceutical, and UCB. Grant/Research Support: AbbVie, Amgen, Eli Lilly, Janssen, and Novartis. Speaker’s Bureau: Celgene, Novartis, Sun Pharmaceutical, UCB, and Valeant Pharmaceuticals Intl/Ortho Dermatologics.
Editorial Support Disclosures
Erin K. Fletcher, MIT, director of compliance and education, Susan Gallagher-Pecha, director of client services and project management Evolve; and Kristen Richardson, writer have no financial relationships with commercial interests., Neil Shah, MD, peer reviewer, has no financial relationships with commercial interests.
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Evolve, Practical Dermatology, or Ortho Dermatologics.
Those of us who treat patients with psoriasis have long recognized the profound quality of life effects of this chronic disease. But recent research suggests that the psychological effects of psoriasis are more complex than a simple response to living with a skin disease associated with stigma. Psychiatric conditions such as depression, anxiety, and suicidal ideation are now understood as comorbidities of psoriasis. The following roundtable brings together expert clinicians to discuss the psychological comorbidities of psoriasis. We will also discuss how clinicians treating patients with psoriasis can screen for these comorbidities. The goal, as always, is to provide the best possible outcome for the whole patient.
– Leon Kircik, MD
Leon Kircik, MD: Our first task is to review the psychological comorbidities associated with psoriasis. Patients with psoriasis bear a greater burden of mental health comorbidities compared with the general population as well as people with other cutaneous conditions.1 In a systematic review of the literature, the estimated prevalence of psychological conditions in people with psoriasis ranged from 24% to 90%.2
Depression is one of the most recognized psychological comorbidities, and patients with psoriasis face an increased risk of depression even after controlling for other comorbidities.3,4 A meta-analysis showed that people with psoriasis were at least 1.5 times more likely to have depression than people without the disease.5 If patients with psoriasis experience stigmatization, have severe pruritus, or have been diagnosed with psoriatic arthritis, they are more likely to have depression.6
There is also a high prevalence of anxiety among adult patients with psoriasis compared to those without the disease.7 Anxiety is slightly elevated in patients with psoriasis compared to people with other dermatologic diseases.1
Jerry Bagel, MD, MS: We need to do a better job recognizing depression in our patients with psoriasis. There’s an article that looked at the concordance between clinical assessments of depression and anxiety by dermatologists and assessments made using the Hospital Anxiety and Depression Scale (HADS). 8 [HADS is a 14-item patient-administered questionnaire that measures anxiety and depression.9] Only 44% of dermatologists recognized depression in patients who had depression as determined by the HADS.8 So we’re not understanding what our patients are going through.
Richard Fried, MD, PhD: As a psychologist and a dermatologist, I think the concept of subclinical depression is underrecognized in the literature. Every measure we have of depression is based on the classic signs described in the Diagnostic and Statistical Manual of Mental Disorders (DSM). But I think we have more subclinical depression among psoriasis patients. Subclinical depression is basically an overall feeling of blah. Food doesn’t taste as good, flowers don’t smell as sweet, sex — if there is any — doesn’t feel as good. The depression often manifests as a general withdrawal from family and friends. Patients’ interests fade away: They stop coaching the kids, they aren’t interested in going to the movies, they stop playing sports.
The insidious nature of how chronic skin disease robs people not only of their happiness but also of their interactions with people, places, things, and work is underrecognized by standard measures. In addition, patients don’t identify these feelings as depression.
I cannot tell you how many times I’ve had the experience of putting a patient with psoriasis on sertraline or duloxetine along with their biologic, and having their partner come in later and say, “I don’t know what’s in this bottle, what’s in this syringe, but I feel like I’ve gotten my spouse back.”
Jashin Wu, MD: Patients with psoriasis also are at high risk for sleep disorders and sexual dysfunction. Actually, a recent review of the literature cites sleep disorders and sexual dysfunction as the most frequent psychological comorbidities associated with psoriasis (Table 1). So even though we talk about depression and anxiety all the time, the prevalence of sleep disorders and sexual dysfunction, which we probably have not talked about enough in the literature, is even higher.
Dr. Bagel: Does the high prevalence of obesity among patients with psoriasis play a role in sleep disorders?
Dr. Wu: It’s probably all related. Perhaps patients have sleep apnea because they have obesity. Perhaps they can’t sleep because they are scratching all night. I’m sure it’s all related.
Dr. Fried: As are the dysesthesias. It is perhaps underestimated how much psoriatic skin itches, tingles, burns, crawls, or just has diffuse hypersensitivity. Everyone thinks about itch with psoriasis, and if it’s impetiginized or if there are fissures, we think about pain.
I think psoriatic skin often just feels crappy. It wakes people up at night. It makes them feel uncomfortable. It makes them incredibly reticent about any kind of touch, whether it’s a blanket or clothing or someone touching their skin. I think that sleep interlaced with dysesthesia, depression, and alcohol abuse probably interacts and then spirals.
Dr. Bagel: Jennifer Cather, MD, has done interesting work on the sexual component of psoriasis. In a qualitative study of 20 patients with moderate to severe genital psoriasis, 90% reported at least one negative effect on sexual activity, including reduced frequency of sex, avoidance of sexual relationships, and reduced sexual desire.10 In another study, treatment of moderate to severe psoriasis with ustekinumab produced significant improvements in sexual problems.11
Dr. Fried: The Cather study is interesting because it focuses on the subjective experiences of people with psoriasis. Some studies of sexuality and psoriasis focus on the frequency of intercourse and erectile difficulties, and I’m not sure that really taps into the lived experience of patients. Patients ask themselves, “Can I cuddle with my partner? Do I feel comfortable enough to take my shirt off in front of my partner?” I think we’re looking at the tip of the iceberg when we think about sexual dysfunction and psoriasis.
Dr. Bagel: I’d like to ask the group about alexithymia—the difficulty identifying or expressing emotions. A study has estimated the prevalence of alexithymia in patients with psoriasis at 25%.12 I see it a lot in my patients with psoriasis. They’re stoic; they’re like granite. They don’t talk until you ask specific questions like, “When was the last time you went to the beach? When was the last time you got into a hot tub?” Some patients with psoriasis are very emotional, but some just can’t express how they feel. Do other people have thoughts about the concept of alexithymia?
Dr. Fried: Let’s put alexithymia in a few buckets. Bucket number one is patients who don’t know or understand that they have depression. Bucket number two is patients who are terrified to express their emotions. Bucket number three is people who are tuned into their emotions but have no idea how to sort through them or express them. I’m guessing that all of us have had the experience of asking a patient who has had psoriasis for 25 years, “How are you doing, Joe?” And he replies, “Ah, same ol’ same ol’.” Then you look him in the eye and hold eye contact for a few seconds and ask, “Honestly, how difficult is it?” And you watch his eyes start to fill up with tears.
I think those feelings are under the surface for so many people with psoriasis. We don’t always appropriately evaluate these feelings of depression and anxiety because patients aren’t always able to be honest, they aren’t always aware of their feelings, and they may not understand what is going on other than that their lives feel like a total mess. I think sharing with these patients that it’s exceedingly difficult to live with psoriasis while reassuring them that we now have many more effective treatments than we did in the past is so important.
Dr. Kircik: Effective treatment is key. A recently published observational study showed that phototherapy or systemic therapy significantly decreased alexithymia in patients with moderate to severe psoriasis.13 Alexithymia reversed in more than half of patients after one year of treatment. It’s also interesting that excessive use of alcohol was reduced by almost 3-fold.13
Dr. Bagel: Based on the data I’ve read, psoriasis has a greater impact on suicidality than other dermatologic disorders.14 Why?
Dr. Fried: Other than eczema, and some of the more common diffuse skin diseases, there’s not another skin disease that is so capricious in where, when, and with what intensity it shows itself. So what part of your body do you dare expose next Friday night if you’re anticipating an intimate interaction? It’s just so overwhelming and overwhelmingly unpredictable. And then, because of the exuberant presentation of psoriasis, patients have experienced psychosocial rejection and perhaps even bullying in the past. Patients anticipate what the next person is going to say, how the next person is going to react. It leaves patients thinking that they just want to escape. That escape might be in alcohol, it might be in drugs, or it might be in suicide.
Dr. Kircik: Let’s review some of the data on psoriasis and suicide. People with psoriasis are at increased risk for suicidality, which includes suicidal ideation, suicide attempts, and completed suicide. In a recent systematic review and meta-analysis of 18 studies, patients with psoriasis were twice as likely to consider suicide as people without psoriasis.15 Patients with psoriasis had a 32% higher likelihood of attempting suicide than people without psoriasis and a 20% higher likelihood of completing suicide than people without psoriasis.15 Younger patients and patients with more severe disease are at particular risk.15
Dr. Wu: When thinking about psychological comorbidities, we should also mention alcohol consumption and smoking. In my clinical practice, patients with psoriasis tend to struggle more with alcohol and smoking compared with patients with other cutaneous diseases. The data show that as many as one-third of people with moderate to severe psoriasis consume alcohol excessively, and excessive drinking is associated with increased body surface area involvement.16 People with psoriasis also have a significantly greater risk of dying from alcohol-related causes than people without the disease.16 Smoking is an independent risk factor for psoriasis, and people with psoriasis smoke more than people without psoriasis.17
Dr. Kircik: Let’s move on to a discussion of the pathophysiology of psychological comorbidities. Are people with psoriasis depressed because of psychosocial stressors? Are people with psoriasis depressed because of an innate pathologic mechanism that we don’t yet fully understand? Do psoriasis and the psychological comorbidities of psoriasis have an overlapping pathophysiology?
Dr. Wu: It may be a chicken and egg situation, but levels of some proinflammatory cytokines are elevated in both psoriasis and depression.18 Interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-a are all elevated.18 So it may be the chicken and the egg, but I think it also could be the cytokines themselves.
Dr. Fried: It is now being suggested that inflammatory cytokines cross the blood-brain barrier and increase reuptake of neurotransmitters at the level of the synapse.19 So the question becomes, as the panel suggested, is psoriasis depressing because of living with the psychosocial stigma or does the increased reuptake of serotonin, norepinephrine, and dopamine at the synapse give us a clear biological explanation for why patients are depressed and anxious centrally?
Dr. Bagel: Another interesting line of research is that proinflammatory cytokines stimulate indoleamine activity, which catalyzes the conversion of tryptophan to kynurenine.18,19 Kynurenine metabolism dysfunction may contribute to neuropsychiatric conditions.19
Dr. Fried: I think it’s probably all of the above. But I think newer data on depression as an inflammatory disorder and inflammatory skin disorders depleting neurotransmitters centrally, is important and should be recognized.
Dr. Wu: There is a related point that I would like to bring up. As you’re all aware, brodalumab carries a boxed warning for suicidal ideation and behavior and can be prescribed only through a Risk Evaluation and Mitigation Strategy program.20 The drug, which is indicated for the treatment of adult patients with moderate to severe plaque psoriasis, selectively binds to the IL-17 receptor A. Does anyone have any thoughts?
Dr. Bagel: The mechanism of action of brodalumab is different in that it inhibits the IL-17 receptor, compared with the 2 other currently FDA-approved IL-17 inhibitors, secukinumab and ixekizumab, which inhibit the IL-17A molecule itself.21
Dr. Kircik: The role of IL-17 in psychological conditions is not clear currently. One study found that IL-17 was elevated in patients with rheumatoid arthritis, especially those who also had anxiety.22 But another small study found that IL-17 levels were not significantly higher in patients with major depressive disorder compared with controls.23
During the clinical development of brodalumab for psoriasis, there were 4 completed suicides and 10 attempted suicides in brodalumab-treated subjects.24 The majority of these events were during the long-term, open-label phase of the studies. There were no completed suicides during the 12-week placebo-controlled part of the trials. It’s important to note that the brodalumab clinical study program did not exclude subjects with a history of psychiatric events or previous suicide attempts, unlike clinical trials for other recently approved biologics.24
Dr. Wu: We should also note that brodalumab has been shown to improve depression and anxiety. One of the Phase 3 trials of brodalumab, AMAGINE-1, included the outcome of changes in the HADS score.25,26 The HADS questionnaire was given at baseline and at week 12. A greater proportion of brodalumab-treated patients had improvements in anxiety and depression after 12 weeks of treatment compared with patients who received placebo.26
I was a coauthor of a paper by Mark Lebwohl, MD, that evaluated data from clinical trials of brodalumab: a placebo-controlled Phase 2 clinical trial, the open-label, long-term extension of that trial, and the three Phase 3 pivotal trials and their open-label, long term-extensions.27 No causal relationship was found between suicidality and treatment with brodalumab.27
Dr. Bagel: When apremilast, which has a warning for depression, came out, I started asking patients about depression. (See box, below.) But remember, we asked patients about depression when considering acitretin. Once the IL-17s came out, I started asking about personal or family history of inflammatory pathology because of the increased expression of IL-17 in inflammatory bowel disease.
So now, as part of my review of systems, I talk about history of depression and suicidal ideation. But what is the best strategy for a dermatologist to determine the likelihood that a patient has severe depression or might be at risk for suicide?
Dr. Fried: When considering prescribing isotretinoin or when considering prescribing biologics for psoriasis, I ask 3 questions.
Number 1: “When it‘s been one of those weeks, or months, or years and everybody and everything is closing in, has hurting yourself or somebody else ever been an option?”
Number 2 (If the answer to question 1 is “yes”): “What would stop you from doing it?”
Number 3: “Where are you now?”
If a patient is at high risk, I want them to see a psychiatric professional before I prescribe anything.
Dr. Kircik: This brings us to another topic I want to cover, which is screening for the psychological comorbidities of psoriasis. As Dr. Bagel mentioned earlier, studies have shown that dermatologists don’t do a great job recognizing psychological comorbidities such as anxiety and depression.
Several validated instruments are available to assess psychological comorbidities in people with psoriasis. The Columbia Suicide Severity Rating Scale (C-SSRS) is recommended by the FDA to assess suicidality in clinical trials.18 The HADS is frequently used in clinical trials of psoriasis medications, although it can also be used in clinical practice.9
There are more user-friendly options. I use the Patient Health Questionnaire-9, or PHQ-9, on every single psoriasis patient as a baseline (See Table 2). The PHQ-9 asks 9 questions based on DSM criteria to assess depression.28 A small study of patients with mild to moderate psoriasis showed that the PHQ-9, which takes only 1 to 3 minutes to complete, is a useful screening tool.29 I think that sometimes people feel more comfortable filling out a questionnaire rather than having a conversation with their physician. Of course, some patients may be more comfortable talking with a physician.
There is also the PHQ-2, which uses the first 2 questions of the PHQ-9. It isn’t intended to establish a diagnosis of depression but it is a first-step screen.30 Adding the question “Have you had thoughts or plans to hurt yourself or hurt others?” can help detect suicidal ideation.31
Do any of you use validated screening tools?
Dr. Wu: I think it’s a great idea, but I haven’t used any of these validated surveys in my patients in clinic. If I have any sense that they have depression, anxiety, or suicidal ideation, I generally send them straight to the psychiatry department. But in my own clinic, I don’t use screening tools.
Dr. Fried: With the rampant occurrence of depression among adolescents now, anything we can use for the benefit of patients as well as medicolegal considerations is a great idea.
Dr. Kircik: I find the PHQ-9 easy and fast. I think some sort of screening instrument makes sense, both medically and legally, as well as for the good of patients. There aren’t any recognized guidelines for psychological comorbidity screening, but a European expert panel consensus document recommends that patients with psoriasis be assessed regularly for anxiety, depression, and addictive behaviors and referred to a psychiatrist if psychological comorbidities affect psoriasis management or if the dermatologist suspects depression.32 If I see a trend toward depression or suicidality, I suggest that the patient see a psychiatrist.
Dr. Bagel: I think the crucial question is how can we help ourselves—dermatologists—become comfortable evaluating suicidal ideation and depression? And where’s the gray area? What methods can we use? Is it the HADS? I don’t have a good system other than my own questions and intuition.
Dr. Kircik: We have to recognize that dermatologists are pressed for time. It’s similar to screening for psoriatic arthritis: time-consuming but necessary.
Dr. Bagel: Dermatologists had to get used to asking questions about inflammatory bowel disease in patients with psoriasis. Perhaps that’s more straightforward than screening for psychological comorbidities, but the key is for physicians to get comfortable.
Dr. Fried: We have a euphemism in our center: skin emotion specialist. The skin emotion specialists are psychiatrists and psychologists in the community. If we think a patient is at risk for psychiatric comorbidities we’ll say, “We have skin emotion specialists who have extensive experience with psoriasis. I’d love for you to see one of them, because psoriasis in its purest sense is your skin behaving in a neurotic fashion. You’re not neurotic, but your skin is. We’d like you to see a skin emotion specialist once, just to see if there is anything else we can safely add to make your skin feel better. And, given how difficult it is to live with psoriasis, you’ll feel better too.”
Dr Wu: We already mentioned that brodalumab treatment decreased depression and anxiety in the AMAGINE-1 study. I’d also like to note that in the pivotal clinical trials for adalimumab, etanercept, ustekinumab, and infliximab, depressive symptoms decreased with treatment.33 In a study that analyzed patients in the Psoriasis Longitudinal Assessment and Registry (PSOLAR), treatment with biologics appeared to be associated with a lower incidence of depressive symptoms than treatment with traditional systemics and phototherapy in patients with psoriasis.33 In my clinical experience, I can attest that successful treatment of psychological comorbidities has a real effect that greatly improves the lives of people with psoriasis.
Dr. Fried: The unknown entity in any given person is how much clinical improvement is enough to minimize short-and long-term comorbidities. We can measure glycated hemoglobin, we can measure blood pressure, we can even perform cardiac scans for calcification, but we have no scan to determine how people are affected psychologically. We have an obligation to make people with psoriasis as physiologically and psychologically free of burden as we can.
Dr. Bagel: I’ve been around a little longer than some of you: 33 years in private practice. The one thing I learned early on is: how do you make people happier? You make them clear.
Dr. Kircik: And now we have the National Psoriasis Foundation treatment targets for plaque psoriasis.34 The target response 3 months after the initiation of treatment is a body surface area (BSA) of 1% or less. A response of 3% BSA at 3 months is considered acceptable. Evaluation every 6 months during the maintenance period is recommended, and the target response at maintenance evaluations is a BSA of 1% or less.
Dr. Kircik: I’d like to close this discussion by asking each of you for your final thoughts on our topic of the psychological comorbidities of psoriasis.
Dr. Wu: Psoriasis is a terrible disease, so it’s not surprising that many people with psoriasis have concomitant mental health issues. Dermatologists should be aware of these comorbidities and be willing to address them or send patients to a specialist who can.
Dr. Bagel: For 6 months of my dermatology residency at Columbia Presbyterian Medical Center, I worked on the inpatient service, where there were always 30 patients with severe psoriasis who were hospitalized for 1 month. I initiated weekly group therapy sessions in collaboration with a psychiatrist. What soon became apparent is that in addition to being frustrated and angry about their disease, many patients were depressed and experienced suicidal ideation.
Thirty-five years later, we have much better therapies for psoriasis. But until patients receive the appropriate treatment, patients are depressed and many experience suicidal ideation.
Dr. Fried: Clinicians should be aware that each patient with psoriasis has his or her own comorbidity threshold that once crossed results in irreparable damage to the body and psyche. Our obligation is to be sensitive to and vigilant for these comorbidities and to guide our patients toward effective therapies that may avert the many negative sequelae of psoriasis.
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30. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003; 41: 1284-1292.
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