Can behavioral healthcare help the millions worldwide who suffer from psoriasis?

Without a cure, managing the painful symptoms of this disease is the primary objective for caregivers and patients. Clinical evidence suggests that behavioral health and psychological interventions can not only generate statistically significant improvements in wellbeing and anxiety, but they may also reduce the amount of time people spend in the hospital following serious outbreaks.

A "SERIOUS GLOBAL PROBLEM"

Psoriasis is an immune-mediated condition [1] that causes inflammation and more rapid generation of skin cells, leading to plaques and scales on the skin, which can sometimes be painful or itch [2]. 

JAMA_1_V2Worldwide, the prevalence of psoriasis ranges from 0.09% to 11.43%, leading the World Health Organization to recognize it as a “serious global problem” [3]. In the United States alone, over 7.5 million people over the age of 20 are living with psoriasis [4].


THE HIGH COST OF PSORIASIS AND COMORBIDITES

Given the physical, psychological, and social ramifications of psoriasis, there is a tremendous economic burden associated with this particular chronic condition. In the U.S., total costs associated with psoriasis are around $112 billion annually [5], and all cost healthcare expenditures are estimated at approximately $12,523 per patient, per year [6].

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The largest proportion of these costs stem from outpatient treatment followed by prescription costs [7]. These costs per patient increase over time as the disease progresses, and are substantially higher among people with moderate to severe psoriasis, who represent 21-33% of people diagnosed with psoriasis [6]. 

Itching, pain, or scaling (i.e., patches on the skin from psoriasis) associated with psoriasis also interfere with work, leading to missed workdays and lower productivity [8]. In one study, nearly 70% of people with psoriasis reported at least one work absence during the year that was not considered recreational/vacation, and they were at least 1.4x more likely to have a non-recreational work absence compared to healthy controls. Fifty-six percent also reported taking sick leave and were at least 1.4x more likely to do so compared to healthy controls.

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This amounts to an estimated cost to employers of $1657 per patient, per year due to missed work days alone [9].  The negative impact of psoriasis in the workplace is even greater among those with moderate to severe psoriasis. In a survey of adults with moderate to severe psoriasis, 37% of respondents indicated losing between 3 and 10 work days during the previous three months due to psoriasis treatment [10].

Part of what makes psoriasis such a costly disease is that it also increases the risk of developing several other chronic health conditions including psoriatic arthritis, chronic pulmonary disease, diabetes, liver disease, peptic ulcer disease, peripheral vascular disease, renal disease, rheumatologic disease, and heart attack [11].
These comorbidities account for approximately $36.4 billion of the costs associated with psoriasis [5]. 

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Compared to people without psoriasis, healthcare costs are 50% higher among psoriasis patients without any comorbidities, 168% higher among psoriasis patients with 1-2 comorbidities, and 494% higher among psoriasis patients with 3 or more comorbidities. Similarly, indirect work-loss related costs are 52% higher among psoriasis patients with no comorbidities, 105% higher among those with 1-2 comorbidities, and 267% higher among those with 3 or more comorbidities [7]. 

The Psychological Toll of Psoriasis


While psoriasis is associated with a higher risk for various physical conditions, the visible nature of scaling and perceived stigma related to psoriasis also tends to elicit distress among psoriasis patients including embarrassment, shame, low self-esteem, and self-consciousness [12]. These high levels of distress negatively impact mental health, particularly when psoriasis patches are visible [13]. Studies suggest that 10% of psoriasis patients experience clinical levels of depression, and nearly twice that number report depressive symptoms more broadly; these levels are significantly higher than what is reported by healthy controls [14]. The relationship between psoriasis and depression may not just be a result of self-consciousness; some researchers argue that psoriasis patients are also predisposed to depression because of the inflammatory response caused by psoriasis [15]. 

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Consistent with these statistics, a recent survey of 246 American adults with psoriasis or psoriatic arthritis conducted by our Twill Care for Psoriasis team found that 43.31% of survey respondents 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.1 The majority of survey respondents (64.89%) also said their mental health difficulties interfered with their personal relationships and social activities.

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 As one Twill Care for Psoriasis member described it, they didn’t “want to interact with people or sometimes even get out of bed because it seems like a mountain is in front of you without any of the right equipment.

Not surprisingly, these concerns have been compounded by the COVID-19 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 during the pandemic. 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.   

Coping with the Impact of Psoriasis on Mental Health

Given the high levels of distress among psoriasis patients, and that psychological stress may act as a trigger for skin flares among some psoriasis patients [16], researchers have argued that an important component of a psoriasis management plan should include addressing mental health [17]. Indeed, there’s some evidence to suggest that mindfulness-based cognitive therapy [18] and cognitive behavioral therapy (CBT) [19] may be effective for psoriasis patients, and some preliminary research has even shown that psychological interventions may have benefits for psoriasis outcomes as well. For example, one study found that psoriasis patients who participated in a psychological intervention targeting stress and anxiety had shorter hospitalizations [20]. 

In our own research, we’ve shown that people with chronic health conditions have lower levels of wellbeing to begin with, but improve at the same rate as healthy controls while using Twill[21]. More recently, we analyzed data from 219 Twillusers with self-reported psoriasis.2 We found that when these users completed at least 16 activities on Twill, as recommended, they experienced statistically significant improvements in both wellbeing and anxiety compared to users who completed less than the recommended 16 activities.3 More specifically, users who completed at least 16 activities improved their happiness scores by 26.8% and improved their anxiety scores by 26.64% between their first and last in-app assessments. HappifyData

These data suggest that digital mental health interventions, even those that are not directly targeting psoriasis patients, may be an effective tool to help people with psoriasis cope with their mental health. Given the negative impact of the COVID-19 pandemic on mental health in general, which may be exacerbated among psoriasis patients who are experiencing worsening symptoms, accessible,  digital solutions are more important than ever. Solutions like Twill may be a useful adjunct to more traditional psoriasis care plans.

Footnotes

1 Depressive symptoms were measured using the Patient Health Questionnaire 2 and anxiety was measured using the Generalized Anxiety Disorder Questionnaire 2; significant symptoms were determined using established cutoff scores of 3 or higher, which are indicative of clinical levels of depression/anxiety [22].
2 To qualify for this analysis, users had to complete at least 2 in-app happiness assessments, complete at least one activity, complete no more than 3 activities before their first happiness assessment, and had to have between 42 and 182 days between their first and last assessments.
3 Twillincludes an in-app assessment, delivered every two weeks to users, which users can choose to complete. This assessment includes the TwillScale, a nine-item proprietary measure of subjective wellbeing, and the 2-item Generalized Anxiety Disorder 2 Scale to measure anxiety symptoms.
 

References

[1] Griffiths, C. E., & Barker, J. N. (2007). Pathogenesis and clinical features of psoriasis. The Lancet, 370(9583), 263-271.
[2] National Psoriasis Foundation. https://www.psoriasis.org/about-psoriasis/ 
[3] World Health Organization. (‎2016)‎. Global report on psoriasis. World Health Organization. https://apps.who.int/iris/handle/10665/204417
[4] 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.
[5] Brezinski, E. A., Dhillon, J. S., & Armstrong, A. W. (2015). Economic burden of psoriasis in the United States: a systematic review. JAMA dermatology, 151(6), 651-658.
[6] Al Sawah, S., Foster, S. A., Goldblum, O. M., Malatestinic, W. N., Zhu, B., Shi, N., ... & Feldman, S. R. (2017). Healthcare costs in psoriasis and psoriasis sub-groups over time following psoriasis diagnosis. Journal of medical economics, 20(9), 982-990.
[7] Pilon, D., Teeple, A., Zhdanava, M., Ladouceur, M., Ching Cheung, H., Muser, E., & Lefebvre, P. (2019). The economic burden of psoriasis with high comorbidity among privately insured patients in the United States. Journal of medical economics, 22(2), 196-203.
[8] Lewis-Beck, C., Abouzaid, S., Xie, L., Baser, O., & Kim, E. (2013). Analysis of the relationship between psoriasis symptom severity and quality of life, work productivity, and activity impairment among patients with moderate-to-severe psoriasis using structural equation modeling. Patient preference and adherence, 7, 199.
[9] Orbai, A. M., Reddy, S. M., Dennis, N., Villacorta, R., Peterson, S., Mesana, L., ... & Walsh, J. (2021). Work absenteeism and disability associated with psoriasis and psoriatic arthritis in the USA—a retrospective study of claims data from 2009 TO 2020. Clinical Rheumatology, 1-10.
[10] Ayala, F., Sampogna, F., Romano, G. V., Merolla, R., Guida, G., Gualberti, G., ... & Daniele Study Group. (2014). The impact of psoriasis on work‐related problems: a multicenter cross‐sectional survey. Journal of the European Academy of Dermatology and Venereology, 28(12), 1623-1632.
[11] Yeung, H., Takeshita, J., Mehta, N. N., Kimmel, S. E., Ogdie, A., Margolis, D. J., ... & Gelfand, J. M. (2013). Psoriasis severity and the prevalence of major medical comorbidity: a population-based study. JAMA dermatology, 149(10), 1173-1179.
[12] 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.
[13] 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.
[14] Dowlatshahi, E. A., Wakkee, M., Arends, L. R., & Nijsten, T. (2014). The prevalence and odds of depressive symptoms and clinical depression in psoriasis patients: a systematic review and meta-analysis. Journal of Investigative Dermatology, 134(6), 1542-1551.
[15] Koo, J., Marangell, L. B., Nakamura, M., Armstrong, A., Jeon, C., Bhutani, T., & Wu, J. J. (2017). Depression and suicidality in psoriasis: review of the literature including the cytokine theory of depression. Journal of the European Academy of Dermatology and Venereology, 31(12), 1999-2009.
[16] 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.
[17] 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.
[18] 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.
[19] 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.
[20] 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.
[21] ​​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.
[22] Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of internal medicine, 146(5), 317-325.