Discourses in Dermatology

This 4-part video series brings together leading dermatologists to explore the intersection of mental health and chronic skin disease, a connection that continues to gain recognition in both research and clinical practice. Across the series, experts examine how psychiatric comorbidities influence dermatologic outcomes, review data on the mental health impact of chronic inflammatory conditions, and discuss how dermatologists can thoughtfully address these concerns in patient care. Psoriasis and the psychiatric comorbidityIn Part 1, Mark Lebwohl, MD, is joined by Rick Fried, MD, PhD, both a dermatologist and a clinical psychologist, to examine the deep and often underappreciated mental health impact of psoriasis. They open with a reminder that multiple dermatologic diseases influence mental health, with psoriasis being among the most studied but far from the only condition with significant psychiatric burden.Dr Lebwohl also outlines 4 dermatologic therapies that carry warnings related to suicidality: brodalumab, isotretinoin, apremilast, and bimekizumab. He notes that concerns about these warnings can meaningfully impact prescribing behavior.The baseline mental health status of patients with psoriasisDr Fried highlights extensive evidence showing that patients with psoriasis have substantially elevated rates of depression, anxiety, suicidal ideation, and completed suicides. Importantly, he notes psoriasis itself is an independent risk factor for these outcomes.He explains that multiple studies show that when psoriasis improves, associated depression and suicidality often also improve, sometimes dramatically, suggesting that treatment of the skin disease can be a direct, positive intervention for a patient’s mental health.Dr Lebwohl reinforces this point with data from a large survey demonstrating that major depression occurs more frequently among people with psoriasis than in the general US population, illustrating the need for dermatologists to recognize and address this burden.When mental health improves with skin disease controlDrawing from his psychology practice, Dr Fried shares that patients with severe psoriasis who have a history of depression or suicidality often benefit the most from highly effective dermatologic treatment, despite clinicians’ hesitations to prescribe when these treatments carry suicidality warnings. These patients frequently experience relief not only from their skin symptoms but also from the social, emotional, family, and intimate impacts of the disease.By the time patients reach dermatology care, many have endured years of topical prescription and over-the-counter treatment failures. He finds that simply engaging with a clinician who demonstrates empathy and confidence in a treatment plan can be impactful for these patients.The dermatologist’s role: life-saving potential through effective treatmentDr Lebwohl stresses that dermatologists may be uniquely positioned to save lives by rapidly improving severe psoriasis with highly efficacious therapy, even if the medication carries a suicidality warning. He notes that FDA labeling reflects a requirement to list all potential events, not proven causation, and that withholding effective therapy due to fear of labeling language may harm patients who need rapid control the most.Dr Fried agrees, emphasizing transparency and informed consent alongside a broader perspective: while labels enumerate theoretical risks, they do not list the severe consequences of undertreatment, including worsening psychiatric burden.Both clinicians highlight that untreated psoriasis is associated with worsening systemic and psychiatric outcomes and that dermatologists should be motivated to act quickly and aggressively when indicated.Closing thoughtsThey conclude by reviewing data demonstrating that biologics across classes are associated with lower rates of suicidal ideation and completed suicides compared to untreated psoriasis and compared to the general population. Studies from the past 20 years consistently show that untreated psoriasis is associated with more than a doubling in suicidal ideation and an approximate 20% increase in completed suicides.Key takeawaysPsoriasis independently increases the risk of depression, anxiety, suicidal ideation, and suicideEffective treatment, especially biologic therapy, can meaningfully reduce psychiatric symptomsDermatologists play a critical role in addressing both physical disease and its mental health consequencesSuicidality warnings on dermatologic drugs reflect reporting requirements, not proven causalityEarly, effective, empathetic intervention can improve quality of life across emotional, social, and physical domainsClick here to view the other videos in the series.

This 4-part video series brings together leading dermatologists to explore the intersection of mental health and chronic skin disease, a connection that continues to gain recognition in both research and clinical practice. Across the series, experts examine how psychiatric comorbidities influence dermatologic outcomes, review data on the mental health impact of chronic inflammatory conditions, and discuss how dermatologists can thoughtfully address these concerns in patient care. The inflammation–depression connectionIn Part 2, Drs Lebwohl and Fried deepen their exploration by discussing the biochemical basis linking psoriasis and depression. Dr Lebwohl begins with an intriguing observation: bupropion, a well-known antidepressant, is also a TNF inhibitor, illustrating biochemical overlap between inflammatory pathways and mood regulation.Some inflammatory mediators elevated in psoriasis are also implicated in depression, suggesting a shared biological landscape beyond the psychosocial burden of visible skin disease.Is depression in psoriasis biologic, psychologic, or both?Dr Fried addresses a longstanding question: are psychiatric symptoms in psoriasis primarily due to disease burden, or are they driven by central biologic mechanisms?He emphasizes that the answer is unequivocally both. Inflammatory cytokines released from skin lesions enter the systemic circulation, cross the blood–brain barrier, and alter neurotransmitter uptake, affecting serotonin, norepinephrine, and dopamine. These changes directly contribute to mood symptoms.This dual mechanism reinforces that addressing inflammation can also address psychiatric symptoms.Future directions: neurotransmitter testing and combined therapiesDr Fried discusses emerging possibilities for objectively measuring neurotransmitters through blood, urine, or imaging strategies. If clinicians could quantify depletion in patients with inflammatory skin disease, they might feel more confident pairing SSRIs or SNRIs with biologics when needed.He highlights growing evidence that depression is, in part, an inflammatory disorder and that antidepressants themselves have anti-inflammatory effects, making them strong potential partners to biologic therapy.Examining suicidality concerns with bimekizumabThe conversation shifts to the suicidality warning for bimekizumab, one of the fastest and most effective psoriasis therapies available. Dr Lebwohl reviews a publication by Blauvelt et al that examined Phase 2 and 3 clinical trial data and found no increased risk of suicidality in patients treated with bimekizumab compared to the general population and compared to patients treated with other IL-17 or IL-23 inhibitors.Despite this, the warning remains on the label, and some clinicians avoid prescribing it. Dr Lebwohl cautions that this hesitancy may prevent high-need patients from accessing a highly effective treatment.Psychological improvement with effective therapyDr Lebwohl closes by sharing another notable trial finding: in pivotal trials, among patients receiving bimekizumab, 93% reported no or minimal depression, compared with 81% of placebo-treated patients. This reinforces that improving skin disease can significantly improve psychological well-being.Key takeawaysPsoriasis and depression may share overlapping inflammatory pathwaysInflammatory cytokines can influence neurotransmitter activity and moodTreating systemic inflammation can improve both skin and psychiatric symptomsClinical trial data show no increase in suicidality with bimekizumab compared with placebo, the general population, or other biologicsClick here to view the other videos in the series.

This 4-part video series brings together leading dermatologists to explore the intersection of mental health and chronic skin disease, a connection that continues to gain recognition in both research and clinical practice. Across the series, experts examine how psychiatric comorbidities influence dermatologic outcomes, review data on the mental health impact of chronic inflammatory conditions, and discuss how dermatologists can thoughtfully address these concerns in patient care. A practical framework for patient conversationsIn Part 3, Drs Lebwohl and Fried turn to the clinician–patient dialogue around therapies that carry suicidal ideation/behavior warnings (SI/B). Dr Lebwohl describes his efficient and effective approach, designed to give patients clarity without overwhelming them.He notes that many patients research their medications and inevitably encounter suicidality language. His strategy involves succinctly explaining that the FDA must list every reported event, even when trial data explicitly state there is no causal association. He then grounds the conversation in data; for example, highlighting that bimekizumab-treated patients demonstrated significantly better mental health outcomes than those on placebo.Reframing the risk: the cost of undertreatmentBoth clinicians emphasize that severe psoriasis itself is associated with increased depression, anxiety, suicidal ideation, and suicide. Effective treatment is a powerful tool for reversing these risks.Dr Lebwohl stresses that when patients are depressed, withholding high-efficacy therapies because of labeling language may cause greater harm. The act of rapidly improving their disease is often the first step toward improving their mental well-being.Communication style: clear, confident, and compassionateDr Fried reinforces the importance of clarity and empathy in these conversations. While shared decision-making is essential, many patients still look to their clinician for a straightforward recommendation.Both experts recommend a structured approach:Acknowledge the SI/B languageExplain the FDA’s reporting requirementsClarify that available data show no causal relationshipHighlight that treating the inflammatory disease can improve mental healthRecommend the therapy you believe is best for the patientThis entire process, Dr Lebwohl notes, takes about one minute in practice.Key takeawaysDermatologists should address SI/B language proactively and confidently with patientsFDA-required labeling reflects reported events, not causationEffective psoriasis treatment reduces psychiatric symptoms and riskClear, compassionate communication strengthens trust and decision-makingPatients often benefit from direct guidance on the clinician’s recommendationClick here to view the other videos in the series.