Review of suicide and depression in psoriasis and management of suicide warnings in patients treated with psoriasis drugs

Patients with psoriasis are thought to be at increased risk of depression, anxiety and suicidality predominantly as a result of the psychosocial impact of this disease. Studies have shown that the pro-inflammatory cytokines that are elevated in psoriasis and targeted by biologics have also been identified in patients with depression. It is therefore thought that anti-cytokine therapies may improve patients’ quality of life not only by reducing their disease burden but also by modulating the inflammatory pathways implicated in depression. While depression is mentioned in the package inserts of brodalumab and apremilast, only brodalumab has a black box warning requiring discussion of suicidality prior to prescribing the drug. In clinical trials, the majority of patients receiving brodalumab experience a reduction in symptoms of depression and anxiety. The package insert for brodalumab points out that no causal association has been established between brodalumab and suicide, and the FDA-mandated Risk Evaluation and Mitigation Strategies (REMS) program for brodalumab takes only minutes to complete. Brodalumab and apremilast may therefore be considered for patients in whom depression is caused by psoriasis, provided that patients and their providers have a mutual understanding of the risks and benefits of these therapies and the REMS program is followed.