Twill’s analysis of healthcare claims data reveals that:
- Depression and anxiety significantly drive up healthcare costs for psoriasis patients
- Roughly half of those with patients who are also diagnosed with Major Depressive Disorder or any anxiety disorder do not have a treatment claim 12 months after their mental health diagnosis
Identifying, educating, and activating these patients sooner would lessen the economic and emotional burden of this disease, which is where digital therapeutics and online care communities can play a key role.
Psoriasis: A serious problem on a global scale
Psoriasis typically results in painful, itchy plaques and scaling of the skin. It is an immune-mediated condition that increases the generation of skin cells, due to inflammation [2, 3].
Worldwide, the World Health Organization (WHO) estimates the prevalence of psoriasis at 0.09% to 11.43%, leading to psoriasis’s designation as a “serious global problem” [4]. In the United States alone, more than 7.5 million people over the age of 20 live with psoriasis every day [5].
Because there is no cure, managing the painful symptoms of psoriasis is typically the primary objective for patients and caregivers. There are serious psychological effects to consider as well; visible scaling and perceived stigma related to psoriasis often elicit feelings of embarrassment, shame, low self-esteem, and self-consciousness [6], especially when patches are visible [7]. Psoriatic arthritis patients also often struggle with poor mental health—one study of mental health comorbidities among people with psoriatic arthritis found that 54% had at least mild to moderate anxiety and 34% had at least mild to moderate depression [8].
Insights from claims data
When Twill’s Health Economics and Outcomes Research team looked at claims data, they found that 48% of all people in the U.S. who have a psoriasis (PsO) diagnosis and are subsequently diagnosed with Major Depressive Disorder (MDD) don’t have a claim for depression treatment within the first year. Similarly, 52% who are diagnosed with Generalized Anxiety Disorder (GAD) or any anxiety disorder do not have a treatment claim at the one-year mark.
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This is not only troubling, but also expensive. When we compared healthcare costs for psoriasis patients who have not been diagnosed with anxiety or depression to those who have been, we discovered that costs are significantly higher[15] for the latter—specifically, an anxiety diagnosis results in an additional $4,181 per person per year and a depression diagnosis, an additional $6,765. Our analysts estimate that reducing the prevalence of anxiety by just 1% would yield an annual cost savings of $13,000,000; for depression, $17,000,000.
The takeaway here—that a significant percentage of this population is struggling with their mental health and not getting the care they need—mirrors the larger trend in this country. The problem is so severe that in his first State of the Union address, President Biden pledged more than $6 billion in his 2023 budget to increase mental health support services in the country.
That funding includes $455 million earmarked for researching new care models and expanding early intervention services. Biden is correct that early intervention is essential to reaching people before they are in crisis because what the aforementioned data doesn’t show is the rate of undiagnosed depression and what that does to costs.
That is why expanding and scaling depression screening and diagnosing mental health problems sooner stands to reduce the nation’s overall healthcare costs, benefiting everyone from health plans and providers to patients.
Addressing mental health for psoriasis patients
Given that psychological stress may act as a trigger for skin flares among some psoriasis patients [9], some researchers have argued that psoriasis management plans should include support for mental health [10].
And there’s evidence to suggest that mindfulness-based cognitive therapy [11] and cognitive behavioral therapy (CBT) [12] are effective for psoriasis patients and may even be able to impact physical outcomes. In one study, psoriasis patients who participated in a psychological intervention targeting anxiety and stress had briefer hospital stays [13].
In my team’s research, we’ve seen that individuals with chronic health conditions tend to start with lower baseline levels of wellbeing, but improve at the same rate as healthy controls when using Twill’s digital therapeutics [14]. Recently, we analyzed data from more than 200 Twill users who self-reported having psoriasis. We found that when these users completed at least 16 activities on Twill, they experienced statistically significant improvements in both wellbeing and anxiety compared to users who completed less than the recommended amount of activities. What’s more, users who completed at least 16 activities saw their happiness scores improve by 26.8% and their anxiety scores by 26.64% between the initial and final in-app assessments.
This suggests that digital mental health interventions, even those that are not directly targeting psoriasis patients, can be effective in helping people with psoriasis improve their well-being and cope better with anxiety.
Making a difference with digital health support
The above research relates to Twill, which broadly targets the causative factors of stress, depression, and anxiety. However, in 2020, Twill launched its Twill Care (formerly Kopa) platform to deliver more condition-specific content and support for the millions of people living with chronic conditions or dealing with health issues related to a particular life stage (i.e. midlife). -1.png?width=494&name=HAP_056_Psoriasis_2_V2%20(1)-1.png)
Twill Care for Psoriasis is a free online community where individuals with psoriasis can exchange information and connect with each other, get advice and guidance from clinical experts, learn about treatment options, and engage with some of Twill’s Therapeutic Media™—evidence-based interventions transformed into interactive digital formats (videos, games, articles, polls, quizzes etc).
To better understand how their psoriasis influences their well-being, we recently surveyed 246 Twill Care for PsO users with psoriasis or psoriatic arthritis and found that 43.31% said “very much” or “extremely” when asked how much their psoriasis or psoriatic arthritis impacted their mental health. What’s more, 35.43% of these survey respondents reported significant depressive symptoms, 40.1% reported significant anxiety symptoms, and 26.7% reported significant symptoms of both. The majority of survey respondents (64.89%) also said their mental health difficulties interfered with their personal relationships and social activities.
Not surprisingly, these concerns worsened during the pandemic. In another survey of 117 Twill Care for Psoriasis members, our research team found that 53% reported feeling more depression, 63% reported feeling more anxiety, and 74% reported feeling more stress since the onset of Covid-19. Furthermore, 54.3% reported experiencing more psoriasis symptoms than usual, and 42.31% reported their psoriasis had more of an impact than usual on their mental health during the pandemic.
Clinical evidence suggests behavioral health and psychological interventions can reduce the amount of time people spend in the hospital following serious outbreaks, not to mention improving their well-being and anxiety. And delivering those interventions digitally means greater access without sacrificing efficacy or further straining providers who are already struggling to keep pace with demand. Digital therapeutics and solutions like Twill Care for Psoriasis can be a useful care plan component, supporting patients’ emotional health and well-being so they can make informed decisions and seek out treatments that work for them.
[1] Hall, J. M., Podawiltz, A., Mummert, D. I., Jones, H., & Mummert, M. E. (2012). Psychological stress and the cutaneous immune response: roles of the HPA axis and the sympathetic nervous system in atopic dermatitis and psoriasis. Dermatology research and practice, 2012.
[2] National Psoriasis Foundation. https://www.psoriasis.org/about-psoriasis/
[3] Griffiths, C. E., & Barker, J. N. (2007). Pathogenesis and clinical features of psoriasis. The Lancet, 370(9583), 263-271.
[4] World Health Organization. (2016). Global report on psoriasis. World Health Organization. https://apps.who.int/iris/handle/10665/204417
[5] Armstrong, A. W., Mehta, M. D., Schupp, C. W., Gondo, G. C., Bell, S. J., & Griffiths, C. E. (2021). Psoriasis Prevalence in Adults in the United States. JAMA dermatology.
[6] Magin, P., Adams, J., Heading, G., Pond, D., & Smith, W. (2009). The psychological sequelae of psoriasis: results of a qualitative study. Psychology, health & medicine, 14(2), 150-161.
[7] Heydendael, V. M., De Borgie, C. A., Spuls, P. I., Bossuyt, P. M., Bos, J. D., & De Rie, M. A. (2004, March). The burden of psoriasis is not determined by disease severity only. In Journal of Investigative Dermatology Symposium Proceedings (Vol. 9, No. 2, pp. 131-135). Elsevier.
[8] Zhao, S. S., Miller, N., Harrison, N., Duffield, S. J., Dey, M., & Goodson, N. J. (2020). Systematic review of mental health comorbidities in psoriatic arthritis. Clinical rheumatology, 39(1), 217-225.
[9] Hall, J. M., Podawiltz, A., Mummert, D. I., Jones, H., & Mummert, M. E. (2012). Psychological stress and the cutaneous immune response: roles of the HPA axis and the sympathetic nervous system in atopic dermatitis and psoriasis. Dermatology research and practice, 2012.
[10] Wu, J. J., Feldman, S. R., Koo, J., & Marangell, L. B. (2018). Epidemiology of mental health comorbidity in psoriasis. Journal of Dermatological Treatment, 29(5), 487-495.
[11] Maddock, A., Hevey, D., D’Alton, P., & Kirby, B. (2019). A randomized trial of mindfulness-based cognitive therapy with psoriasis patients. Mindfulness, 10(12), 2606-2619.
[12] Xiao, Y., Zhang, X., Luo, D., Kuang, Y., Zhu, W., Chen, X., & Shen, M. (2019). The efficacy of psychological interventions on psoriasis treatment: a systematic review and meta-analysis of randomized controlled trials. Psychology research and behavior management, 12, 97.
[13] Li, X., Liu, L., Zhang, Y., & Li, L. (2020). Efficacy of psychological intervention for patients with psoriasis vulgaris: a prospective study. Journal of International Medical Research, 48(10), 0300060520961674.
[14] Parks, A. C., Williams, A. L., Kackloudis, G. M., Stafford, J. L., Boucher, E. M., & Honomichl, R. D. (2020). The effects of a digital well-being intervention on patients with chronic conditions: observational study. Journal of Medical Internet research, 22(1), e16211.
[15] Memish, Ziad A., Jaber S. Alqahtani, and Riyadh A. Almudarra.(2017)The Burden of Non-Communicable Diseases in Transitioning Countries: Challenges for Emergency Physicians. The Journal of Emergency Medicine. 52(2).151-159.
