Journal of Affective Disorders 209 (2017) 229234

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Journal of Aective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Depressiveness, measured with Beck Depression Inventory, in patients with MARK

psoriasis

Daniel Pietrzaka, Aldona Pietrzakb, , Dorota Krasowskab, Marta Makara-Studziskac,
Agata Madejc, Maja Baranowskad, Andrzej Borzckie
a
Department of Anesthesiology and Intensive Care, Medical University of Lublin, Poland
b
Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Poland
c
Department of Applied Psychology, Medical University of Lublin, Poland
d
Institute of Fine Arts, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
e
Department of Hygiene, Medical University of Lublin, Poland

A R T I C L E I N F O A BS T RAC T

Keywords: Background: The aim of this study was to identify demographic and clinical factors predisposing to
Depression depressiveness during the course of psoriasis.
Beck Depression Inventory Method: The study included 239 patients with psoriasis (1576 years, 31.8% of women) and 123 healthy
Skin lesions controls (1774 years, 32.5% of women). Dependent variable in the analysis was Beck Depression Inventory
Risk factors
(BDI) score. Explanatory variables included: age, sex, marital status, education, occupational activity, body
mass index (BMI), systolic and diastolic blood pressure, history of smoking, average number of smoked
cigarettes, skin lesions visible to others, comorbidities, including arterial hypertension and arthritis, number of
previous hospitalizations and family history of psoriasis.
Results: Psoriatics showed higher BDI scores than the controls, and signicantly more often presented with
depressiveness. Depressiveness correlated with psoriasis, older age, female sex, lack of higher education,
occupational inactivity, higher BMI, visible skin lesions, comorbidities, including arterial hypertension and
arthritis, greater number of previous hospitalizations and lack of family history of psoriasis. Multivariate
analysis showed than independent predictors of any grade depressiveness were psoriasis (OR=2.26, 95%CI:
1.114.60, p=0.024), older age (OR=1.03, 95%CI: 1.011.05, p=0.005) and female sex (OR=2.73, 95%CI:
1.455.12, p=0.002).
Limitations: Cross-sectional, non-prospective analysis. Selection bias.
Conclusions: Patients with psoriasis, irrespective of its severity and related complications, are at increased risk
of depressiveness. The risk of secondary depressiveness is particularly high in psoriatic women and older
persons (or individuals diagnosed with psoriasis at younger age). Individuals from this group should be
monitored for potential depressive symptoms.

1. Introduction various authors, depressiveness of varying severity may aect between

Epidemiological data suggest that the incidence of psoriasis still
increases (Parisi et al., 2013). Both the results of many studies and
clinical observations imply that psoriasis, especially severe, is not an
isolated condition but may co-exist with an array of other disease
entities, most of all with the components of the so-called metabolic
syndrome, but also with alcoholism, nicotinism and various mental
disorders (Bohm et al., 2013; Golpour et al., 2012; Parisi et al., 2013;
Strohal et al., 2014). Depressiveness is the most common comorbidity
of psoriasis among the diseases from the latter group. According to
ca. 10% and up to 80% of psoriatic patients, and its risk in this group is
1.5- to 2-fold higher than in psoriasis-free controls (Korman et al.,
2016; Lakshmy et al., 2015).
Concomitant depressiveness exerts a detrimental eect on clinical
outcome of psoriasis; interestingly, this relationship seems to be
bidirectional: depressiveness is reected by greater severity of psoriatic
symptoms, and presence of skin lesions exacerbates the course of
depressive disorder. Since depressiveness is widely known to interfere
with medication adherence (Connor et al., 2015), and thus also with
the treatment outcome, a kind of vicious circle develops (Fig. 1).

Corresponding author.
E-mail address: aldona.pietrzak@umlub.pl (A. Pietrzak).

http://dx.doi.org/10.1016/j.jad.2016.11.045
Received 27 August 2016; Received in revised form 22 October 2016; Accepted 15 November 2016
Available online 30 November 2016
0165-0327/ 2016 Elsevier B.V. All rights reserved.
D. Pietrzak et al. Journal of Affective Disorders 209 (2017) 229234

2. Methods

2.1. Participants

The study included 239 patients with psoriasis (median age 48

Fig. 1. Factors predisposing to depression during the course of psoriasis.
Table 1
Statistical characteristics of BDI scores, prevalence of depression and its severity among
patients with psoriasis and controls.
years, range 1576 years), among them 76 (31.8%) women and 163
(68.2%) men, and 123 healthy controls (median age 42 years, range
1774 years), among them 40 (32.5%) women and 83 (67.5%) men.
Psoriatic patients were recruited at the Department of Dermatology,
Venereology and Pediatric Dermatology, Medical University of Lublin
(Poland) between 2014 and 2016. Median duration of psoriasis was
456.3 months (range 2.51642.5 months) and median PASI score
equaled 22 (range 043.5). Control group was formed of volunteers
treated due to other reasons, such as pigment nevi, mild acne, small
liform warts and fungal nail infections. Aside from providing written
informed consent, the only inclusion criterion of the study was
presence of active psoriasis. The exclusion criteria were: history of a
recent myocardial disease, renal insuciency, severe systemic diseases
with fever, and mental disorders, past or present treatment with
biologicals or immunosuppressive agents. Furthermore, neither psor-
iatics nor the controls received any medications that might interfere
with their depressiveness levels.

Parameter Psoriasis Controls (n=123) p-value 2.2. Ethics

(n=239)

Overall BDI score, points 11.00 (0.00 5.00 (0.0037.00) < 0.001 The protocol of the study was approved by the Local Bioethics
47.00) Committee at the Medical University of Lublin (decision no. KE-0254/
Individual BDI items, points: 283/2014 of 30 October 2014) and written informed consent was
BDI-A 0.00 (0.003.00) 0.00 (0.002.00) < 0.001

sought from all the study subjects.

BDI-B 1.00 (0.003.00) 1.00 (0.003.00) < 0.001
BDI-C 0.00 (0.003.00) 0.00 (0.003.00) < 0.001
BDI-D 0.00 (0.003.00) 0.00 (0.003.00) < 0.001 2.3. Analyzed variables
BDI-E 0.00 (0.003.00) 0.00 (0.002.00) 0.001
BDI-F 0.00 (0.003.00) 0.00 (0.003.00) < 0.001 During routine control visit in the clinic, each participant was asked
BDI-G 0.00 (0.003.00) 0.00 (0.002.00) < 0.001
BDI-H 0.00 (0.003.00) 0.00 (0.002.00) < 0.001
to complete Beck Depression Inventory (BDI). This instrument in-
BDI-I 0.00 (0.003.00) 0.00 (0.001.00) < 0.001 cludes 21 items, each scored on a 4-point scale, from 0 to 3. Final score,
BDI-J 0.00 (0.003.00) 0.00 (0.003.00) < 0.001 ranging between 0 and 63 points, reects presence of depressiveness
BDI-K 1.00 (0.003.00) 0.00 (0.003.00) 0.001 and severity thereof. The result is interpreted as the lack of depression
BDI-L 0.00 (0.003.00) 0.00 (0.003.00) 0.001

(011 points), mild depression (1226 points), moderate depression

BDI-M 1.00 (0.003.00) 0.00 (0.002.00) 0.003
BDI-N 0.00 (0.003.00) 0.00 (0.002.00) < 0.001
(2749 points) or severe depression (5063 points). Examination with
BDI-O 0.00 (0.003.00) 0.00 (0.003.00) < 0.001 BDI may refer to any period in the past, for example to the last month
BDI-P 1.00 (0.003.00) 0.00 (0.003.00) < 0.001 preceding control visit, as it was the case in our patients. The
BDI-Q 1.00 (0.003.00) 0.00 (0.0010.00) < 0.001 instrument showed very good internal consistency rate, as demon-
BDI-R 0.00 (0.003.00) 0.00 (0.001.00) < 0.001
BDI-S 0.00 (0.003.00) 0.00 (0.003.00) < 0.001
strated by Cronbach's alpha equal to 0.91.
BDI-T 1.00 (0.003.00) 0.00 (0.002.00) < 0.001 The list of analyzed explanatory variables included: age, sex, marital
BDI-U
Depression any grade, n
0.00 (0.003.00)
118 (49.6%)
0.00 (0.003.00)
19 (15.7%)
0.005
< 0.001
status, education, occupational activity, body mass index (BMI),
systolic and diastolic blood pressure (SBP and DBP), history of
(%) smoking, average number of smoked cigarettes, presence of skin
Depression severity, n (%):
Mild 87 (36.3%) 15 (12.4%) 0.780
lesions visible to others, comorbidities, including arterial hypertension
Moderate 31 (13.0%) 4 (3.3%) and arthritis, number of previous hospitalizations and family history of
Severe 0 (0.0%) 0 (0.0%) psoriasis.

2.4. Statistical analysis

Moreover, recent evidence suggests that occurrence of depression
during the course of psoriasis is a signicant risk factor for cardiovas-
cular disorders, such as myocardial infarction, stroke and arrhythmia
(Egeberg et al., 2016), and may result in suicidal attempts (Gupta and
Guptat, 2001; Russo et al., 2004).
All the data mentioned above justify the identication of psoriatic
patients predisposed to depressiveness and providing them with a
complex care, including psychological support. Consequently, the aim
of this study was to identify demographic and clinical factors predis-
posing to depressiveness during the course of psoriasis.
Normal distribution of continuous variables was veried with
Shapiro-Wilk test. Statistical characteristics of continuous variables
were presented as medians and ranges, and statistical characteristics of
discrete variables as numbers and percentages. Intergroup compar-
isons of continuous variables were based on Mann-Whitney U-test and
Kruskal-Wallis test, and intergroup comparisons of discrete variable
distributions on Pearson's chi-square test and Fisher's exact test. Power
and direction of relationships between pairs of variables were assessed
based on Spearman rank correlation coecients (R). Power and
direction of associations between the presence of depression of any
grade, demographic and clinical variables were assessed using uni-
variate and multivariate logistic regression models. Odds ratios (ORs)
for co-existence of depression with explanatory variables were calcu-

230
D. Pietrzak et al.
Fig. 2. Distribution of educational levels (A), occupational activity (B), prevalence of skin lesions (C), comorbidities (D), arterial hypertension (E) and arthritis (F) in psoriatic patients
and healthy controls.
lated, along with their 95% condence intervals (95%CIs). All calcula-
tions were carried out with Statistica 10 package (StatSoft, Tulsa, OK,
United States), with the threshold of statistical signicance set at
p0.05.
3. Results
Psoriatic patients showed signicantly higher BDI scores than the
controls. Detailed analysis showed that individuals with psoriasis were
also characterized by signicantly higher scores for all individual BDI
items. As a result, psoriatic patients presented with depressiveness
signicantly more often than the controls. However, the two groups did
not dier signicantly in terms of depressiveness severity (Table 1).
Moreover, psoriatic patients were characterized by signicantly
higher BMI, SBP and number of previous hospitalizations, more often
lacked higher education, were occupationally inactive, and more
frequently presented with skin lesions visible to others and other
comorbidities, including arterial hypertension and arthritis (Fig. 2,
Table 2).
Then, we analyzed if aside from psoriasis, the values of dependent
variables, i.e. BDI scores and prevalence of depressiveness, were also
modulated by other demographic and clinical parameters. We found
signicant associations between higher BDI scores and older age,
higher BMI, SBP and DBP, larger number of previous hospitalizations,
female sex, lack of higher education, lack of occupational activity,
presence of visible skin lesions, comorbidities, including arterial
231
Journal of Affective Disorders 209 (2017) 229234
hypertension and arthritis, and lack of family history for psoriasis
(Table 3).
In turn, depressiveness of any grade correlated signicantly with
presence of psoriasis, older age, female sex, lack of higher education,
occupational inactivity, higher BMI, presence of visible skin lesions,
comorbidities, including arterial hypertension and arthritis, greater
number of previous hospitalizations and lack of family history of
psoriasis (Table 4).
Multivariate analysis showed than independent predictors of any
grade depressiveness were presence of psoriasis (OR=2.26, 95%CI:
1.114.60, p=0.024), older age (OR=1.03, 95%CI: 1.011.05,
p=0.005) and female sex (OR=2.73, 95%CI: 1.455.12, p=0.002)
(Table 4).
4. Discussion
Our observation that the risk of depressiveness increases with age is
consistent with the results of a study conducted among 980 patients
with psoriasis or psoriatic arthritis. This study, identied age above 45
years as an independent predictor of depressive disorders (Wu et al.,
2016). However, the relationship between age of psoriatic patients and
prevalence of depressiveness is not straightforward. In a Danish
population-based study including 35,001 patients with mild psoriasis
and 7 510 with severe psoriasis, new-onset depression was detected in
23.9% and 31.6% of the participants, respectively. After adjustment for
comorbidities, psoriasis was an independent predictor of depression
D. Pietrzak et al. Journal of Affective Disorders 209 (2017) 229234

Table 2 Table 3
Demographic and clinical characteristics of patients with psoriasis and controls. Associations between BDI scores, demographic and clinical characteristics of the study
participants.
Parameter Psoriasis Controls p-value
(n=239) (n=123) Parameter BDI (points) or R p-value

Age (years) 48.00 (15.00 42.00 (17.00 0.296 Age (years) R=0.301 < 0.001
76.00) 74.00) Sex:
Sex, n (%): Female 13.00 (0.0047.00) < 0.001
Female 76 (31.8%) 40 (32.5%) 0.906 Male 6.00 (0.0044.00)
Marital
Male 163 (68.2%) 83 (67.5%) Marital status:
status, n (%): Single 10.00 (0.0044.00) 0.205
Single 76 (31.8%) 34 (27.6%) 0.470 Married 8.00 (0.0047.00)
Education,
Married 163 (68.2%) 89 (72.4%) Education:
n (%): Primary 11.50 (0.0038.00) < 0.001
Primary 46 (19.3%) 8 (6.5%) < 0.001 Vocational 12.00 (0.0047.00)
Vocational 62 (26.1%) 10 (8.1%) Secondary 10.00 (0.0039.00)
Secondary 99 (41.6%) 43 (35.0%) Higher 5.00 (0.0028.00)
Education,
Higher 31 (13.0%) 62 (50.4%) Education:
n (%): Non-higher 11 (0.0047.00) < 0.001
Non-higher 208 (87%) 61 (49.6%) < 0.001 Higher 5.00 (0.0028.00)
Occupational
Higher 31 (13%) 62 (50.4%) Occupational activity:
activity, n (%): Yes 6.00 (0.0047.00) < 0.001
Yes 125 (52.3%) 102 (82.9%) < 0.001 No 12.00 (0.0039.00)
BMI
No
(kg/m ) 2
114 (47.7%)
27.04 (17.26
21 (17.1%)
25.96 (16.98 0.016
BMI (kg/m2)
SBP (mm Hg)
R=0.181
R=0.107
0.001
0.045
46.17) 35.88) DBP (mm Hg) R=0.105 0.049
SBP (mm Hg) 130.00 (90.00 125.00 (90.00 0.008 Smoking:

DBP (mm Hg)

186.00)
80.00 (49.00
167.00)
80.00 (55.00 0.297
Yes 9.00 (0.0047.00)
9.00 (0.0039.00)
0.655

Smoking, n (%):
119.00) 110.00) Number
No
of cigarettes (n) R=0.040 0.619
Yes 113 (47.3%) 50 (40.7%) 0.265 Skin lesions:
Number
No 126 (52.7%) 73 (59.3%) Yes 11.00 (0.0047.00) < 0.001
of cigarettes (n) 15.00 (3.00
60.00)
10.00 (1.00
60.00)
0.190 No
Comorbidities:
6.00 (0.0039.00)

Skin lesionsa, n (%): Yes 12.00 (0.0047.00) < 0.001

Yes 163 (69.4%) 27 (22.0%) < 0.001 No 5.00 (0.0044.00)
Comorbidities,
No 72 (30.6%) 96 (78.0%) Arterial hypertension:
n (%): Yes 13.50 (0.0047.00) < 0.001
Yes 165 (69.0%) 53 (43.1%) < 0.001 No 8.00 (0.0044.00)
Arterial
No 74 (31.0%) 70 (56.9%) Arthritis:
hypertension, n (%): Yes 12.00 (0.0047.00) < 0.001
Yes 55 (23.0%) 5 (4.1%) < 0.001 No 6.50 (0.0044.00)
Arthritis,
No
n (%):
184 (77.0%) 118 (95.9%) Number of hospitalizations (n)
Family history of psoriasis:
R=0.411 < 0.001

Yes 85 (44.3%) 40 (32.5%) 0.045 Yes 8.00 (0.0047.00) 0.038

Number
No
of hospitalizations
107 (55.7%)
4.00 (0.0065.00)
83 (67.5%)
0.00 (0.0018.00) < 0.001
No 12.00 (0.0044.00)

(n) Statistical characteristics of continuous variables presented as medians (ranges).

Family history of psoriasis, n (%):
Yes 189 (82.9%) 106 (86.9%)
No 39 (17.1%) 16 (13.1%)
a
Skin lesions present in the controls: warts with no signs of inammation, liform
lesions without concomitant inammation, fungal infections, pigment nevi.
solely in subjects below 50 years of age, suering from severe form of
the disease. In this study, the incidence of depression was assessed on
the basis of prescription of antidepressants (Jensen et al., 2016).
Analysis of literature data suggests that the relationship between
patient age and prevalence of depressiveness may be explained by
young age at diagnosis of psoriasis. Such explanation is inter alia
suggested by the results of a cohort study involving 114 adolescents
and young adults with psoriasis; in this study, subjects who have been
diagnosed with psoriasis at younger age signicantly more often were
depressed and attributed this phenomenon to their primary condition
(Kim et al., 2015). Also in a cross-sectional study conducted among 101
Swedish patients with psoriasis, young age at the onset of the disease (
< 20 years) was an independent predictor of depression diagnosed with
BDI (Remrod et al., 2013). A Turkish study did not show a relationship
between the prevalence of depression (detected with an aid of BDI) in a
group of 50 psoriatic patients and the time elapsed from diagnosis of
the primary condition (Akay et al., 2002). We did not consider the age
at diagnosis and duration of psoriasis in our analysis and therefore, are
0.359
unable to verify our ndings against published evidence.
Female sex was also an independent predictor of depression,
diagnosed with the Hospital and Anxiety Depression Scale (HADS),
in a multicenter prospective Spanish study of 164 psoriatic patients
(Pujol et al., 2013). Another study, also conducted with HADS among
100 psoriatics aged 2160 years, did not document a signicant
association between the prevalence of depression and patient sex. It
cannot be excluded that the results of this study were confounded due
to a relatively low prevalence of depressive disorders among its
participants (15%) (Tee et al., 2016). Higher risk of depressiveness
among women seems to be consistent with demographic characteristics
of patients in whom this condition developed as an independent entity
or during the course of other chronic diseases (Twomey et al., 2015).
Previous studies identied a few other factors predisposing to
depressiveness during the course of psoriasis, such as severity of the
primary condition (Jensen et al., 2016; Pujol et al., 2013), presence of
psoriatic lesions on the head (Pujol et al., 2013), psoriatic arthritis
(Dommasch et al., 2015; Wu et al., 2016), and other comorbidities (Wu
et al., 2016). Similar to a previous American population-based study
(Cohen et al., 2016), we did not nd a signicant association between
the severity of psoriasis and the prevalence of depressiveness. Other
factors: presence of skin lesions visible to others, psoriatic arthritis and
other comorbidities did not show a signicant association with the

232
D. Pietrzak et al. Journal of Affective Disorders 209 (2017) 229234

Table 4
Predictors of depression among participants of the study; results of univariate and multivariate analysis.

Parameter OR (95%CI) p-value OR (95%CI) p-value

Psoriasis 5.28 (3.039.19) < 0.001 2.26 (1.114.60) 0.024

Age (years) 1.04 (1.021.06) < 0.001 1.03 (1.011.05) 0.005
Female sex 2.60 (1.644.12) < 0.001 2.73 (1.455.12) 0.002
Single marital status 1.18 (0.741.88) 0.487
Non-higher education 3.95 (2.187.16) < 0.001 2.84 (0.845.92) 0.110
Occupational inactivity 2.53 (1.623.96) < 0.001 2.28 (0.642.09) 0.184
BMI (kg/m2) 1.10 (1.041.15) < 0.001 1.03 (0.971.12) 0.146
SBP (mm Hg) 1.01 (1.001.03) 0.142
DBP (mm Hg) 1.02 (1.001.04) 0.113
Smoking 0.93 (0.611.42) 0.741
Number of cigarettes (n) 1.00 (0.971.04) 0.793
Skin lesions 2.75 (1.754.34) < 0.001 2.12 (0.984.10) 0.099
Comorbidities 4.91 (2.958.18) < 0.001 4.01 (0.888.08) 0.098
Arterial hypertension 3.53 (1.976.30) < 0.001 3.43 (0.976.11) 0.094
Arthritis 2.54 (1.584.10) < 0.001 1.98 (0.793.56) 0.103
Number of hospitalizations (n) 1.05 (1.021.08) < 0.001 1.01 (0.901.07) 0.118
No family history of psoriasis 2.23 (1.234.03) 0.008 1.72 (0.653.88) 0.199

prevalence of depressiveness. The nding that presence of visible skin Acknowledgements

lesions was not associated with greater depressiveness is quite surpris-
ing. Perhaps this was patients self-perception that contributed to their
depressive mood since the presence of skin lesions visible to others did
not matter? This aspect seems to be a reasonable direction of future
research. The remaining variables that have been identied as sig-
nicant predictors of depressiveness on univariate but not on multi-
variate analysis, i.e. excess body weight, unemployment and lower
educational level, are widely established correlates of depressive
disorders in general population (Twomey et al., 2015).
4.1. Limitations
Our study was not free from potential limitations. The rst of them
is cross-sectional, non-prospective, character of the analysis. As a
result, we were unable to determine the exact timing of psoriasis and
depressiveness development. Consequently, some patients might have
been predisposed to depressiveness already before being diagnosed
with psoriasis. Another potential drawback of this study is selection
bias; the study included solely the subjects who have been treated at a
tertiary center, and therefore its results probably cannot be generalized
onto whole population of psoriatic patients. Finally, some may consider
the fact that control group was comprised of dermatological patients,
rather than of healthy subjects, as an important limitation of this study.
However, our primary objective was to identify factors that discrimi-
nate individuals being particularly predisposed to depression in a
clinical setting, i.e. among other patients. Nevertheless, the hereby
presented ndings need to be also veried against a control group of
healthy volunteers during future studies.
5. Conclusions
Patients with psoriasis, irrespective of its severity and related
complications, are at increased risk of depressiveness. The risk of
secondary depressiveness is particularly high in psoriatic women and
older persons (or individuals diagnosed with psoriasis at younger age).
Individuals from this group should be monitored for potential depres-
sive symptoms.
Funding source
The study was supported from the Medical University of Lublin
funds (Grant no. DS 168/2016).
The Authors would like to express their gratitude to dr. Szymon
Bruzewicz (SciencePro) for his assistance in writing this manuscript.
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