1. Suicide ideation in psoriasis
Dr Anthony Bewley

2. Introduction
It is predicted that
The World Mental Health Initiative Surveys (2001–2004) highlighted the co-occurrence of mental health disorders and physical conditions2,3
by 2030
depressive mental health disorders will be the
Measuring and monitoring the mental health of patients with physical disorders could contribute to the overall measurement of the burden of disease
2nd
leading cause
of disease burden1
Patient care might be inadequate if their mental health is not addressed
Suicidal ideation, also known as suicidal thoughts, are thoughts about how to commit suicide. These can range from fleeting or passing considerations, to in-depth plans
1. Mathers CD, Loncar D. PLoS Med. 2006;3(11):e442.
2. Scott KM, et al. J Affect Disord. 2007;103(1):
3. Scott KM, et al. Psychosomatic Medicine. 2010;72(7):

3. Suicide ideation prevalence
Suicidal behaviour in dermatology
Several European studies have found that patients with dermatological conditions, such as eczema and acne, have an increased risk of developing clinical depression1-3
Other studies highlight a high prevalence of suicidal ideation and an increased likelihood of attempting suicide in these patient groups4-6
There are clear and significant associations between eczema, acne and psoriasis with suicidal thoughts:7-9
Suicide ideation prevalence
Eczema, N=2350 (OR, 95%CI)
1.87 (1.31–2.68)7
Acne, N=2995 (OR, 95%CI)
1.80 (1.30–2.50)8
Psoriasis, N=149,998 (HR, 95% CI)
1.44 (1.32–1.57)9
CI, confidence interval; OR, odds ratio
1. Cvetkovski R, et al. Contact Dermatitis. 2006;54(2)
2. Dalgard F, et al. J Am Acad Dermatol. 2008;59(5):
3. Onderdijk AJ, et al. J Eur Acad Dermatol Venereol. 2013;27(4):
4. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
5. Sundstrom A, et al. BMJ. 2010;341:c5812.
6. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):
7. Halvorsen JA, et al. J Invest Dermatol. 2014;134(7):
8. Halvorsen JA, et al. J Invest Dermatol. 2011;131(2):
9. Kurd SK, et al. Arch Dermatol. 2010;146(8):

4. Severe psychological symptoms
Suicidal behaviour in dermatology
In patients with common skin diseases (n=3635), compared with controls (n=1359), Dalgard et al1 found a significantly higher prevalence of:
Clinical depression
Anxiety
Suicidal ideation
10.1%
4.3%
17.2%
11.1%
12.7%
8.3% vs vs vs
Female dermatological patients (n=299) consistently exhibit more severe psychological symptoms than male patients (n=201) (p<0.001)2
Severe psychological symptoms
1. Dalgard FJ, et al. J Invest Dermatol. 2015;135(4):
2. Zachariae R, et al. Acta Derm Venereol. 2004;84(3):

5. Psoriasis and suicide >10%
Patients with psoriasis are at an increased risk for suffering from psychological comorbidities such as suicidal ideation, compared to patients with other dermatological conditions1
A European meta-analysis of 26 studies comparing patients with psoriasis (n=264,568) with healthy controls (n=1,174,612), found that
Compared with control groups and patients with other dermatologic conditions, patients with psoriasis have higher rates of
Stress, physical limitations and social stigma further the mental health issues experienced by patients with psoriasis6
Depression
Self-harm
Anxiety
Suicidal thoughts3-5
of patients with psoriasis >10% are clinically depressed2
>10%
1. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
2. Dowlatshahi EA, et al. J Invest Dermatol. 2014;134(6):
3. Kurd SK, et al. Arch Dermatol. 2010;146(8):
4. Dalgard FJ, et al. J Invest Dermatol. 2015;135(4):
5. Singhal A, et al. J R Soc Med. 2014;107(5):
6. Hrehorow E, et al. Acta Derm Venereol. 2012;92(1):67-72.

6. Suicide ideation in psoriasis
Studies: Dalgard et al
A large-scale study (N=4994, 3635 dermatology patients and 1359 controls) of the psychological burden of skin diseases found
Psoriasis was the only dermatological disease significantly associated with suicidal thoughts1
12.4%
patients with dermatological diseases reported suicidal ideation (N=3635)
1. Dalgard FJ, et al. J Invest Dermatol. 2015;135(4):

7. Suicide ideation in psoriasis
Studies: Dalgard et al
68%
of patients with psoriasis reporting suicidal thoughts, stated that their skin was the cause of their considering suicide1
1.94
Suicidal ideation in patients with common skin disorders (N=4994)
Psoriasis
Non-melanoma skin cancer
Nevi
Atopic eczema
Leg ulcers
Benign skin tumours
Hand eczema
Acne
Control
Eczema
Skin infections
1. Dalgard FJ, et al. J Invest Dermatol. 2015;135(4):

8. Suicide ideation in psoriasis
Studies: Gupta et al
A North American study examining the prevalence of depression, death wishes and suicidal ideation was carried out in 480 patients with dermatological disorders that may be considered cosmetically disfiguring1
Severely affected inpatients
Less severely affected outpatients
This study divided patients with psoriasis into two groups
As it has been noted that depression increases with psoriasis severity2
1. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
2. Gupta MA, et al. Int J Dermatol. 1993;32(3):

9. Suicide ideation in psoriasis
Studies: Gupta et al
The prevalence of acute suicidal ideation was
in patients with severe psoriasis1
Other studies report a prevalence of
among general medical patients1-4
7.2%
2.4–3.3%
Suicidal ideation in patients with common skin disorders (N=480)1
7.2
1. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
2. Zimmerman M, et al. J Gen Intern Med. 1995;10(10):
3. Cooper-Patrick L, et al. JAMA. 1994;272(22):
4. Olfson M, et al. J Gen Intern Med. 1996;11(8):

10. Suicide ideation in dermatology patients
Studies illustrate how crucial it is that psychiatric comorbidity is recognised, especially depression, among patients with dermatological conditions1,2
Dermatological disorders considered to be mild or moderate can be associated with significant increases in the likelihood of depression and suicidal ideation1
Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
Cotterill JA, Cunliffe WJ. Br J Dermatol. 1997;137(2):

11. Atopic dermatitis (AD)
Other dermatological diseases and suicide
Aside from psoriasis, the most studied dermatological conditions in relation to suicidal ideation are
Acne
Atopic dermatitis (AD)
There are several studies that reported a high prevalence of suicidal ideation in patients with acne
Studies from several countries show a similar prevalence of suicidal thoughts in severe AD
Study country (N)
Pakistan (50)1
Italy (466)2
North America (72)3
Germany (181)4
Denmark (95)5
Japan
(4400)6 20
Prevalence of suicide ideation (%)
Severe disease 8 7 6 21 19 6
Moderate disease
Overall, the results of these studies suggest that patients with moderate to severe cases of acne or AD may be at a higher risk of attempting and completing suicide
1. Khan MZ, et al. J Ayub Med Coll Abbottabad. 2001;13(4):7-8.
2. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):
3. Gupta MA, Gupta AK. Br J Dermatol. 1998;139(5):
4. Dieris-Hirche J, et al. Acta Derm Venereol. 2017;97:
5. Zachariae R, et al. Acta Derm Venereol. 2004;84(3):
6. Kimata H. Suicide Life Threat Behav. 2006;36(1):

12. There are several risk factors for suicide, including
Male gender*
Adolescent and young adult
Widowed, divorced or unmarried
Substance abuse
Personal depression
Family history of mental health disorders
Severe or chronic physical illness
Unemployment .
*Though men are statistically more likely to commit suicide than women, it is known that female patients are more likely to develop psychodermatological problems than male patients with skin disorders1
1. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):

13. Do not fear a direct question
“Just ask”
Do not fear a direct question ?
Discussing suicide does not make it more likely that the patient will consider it
It is actually more probable that discussing it will mean that the patient is relieved that they are able to be open and understood1
1. Am J Psychiatry. 2003;160(11 Suppl):1-60.

14. What are the benefits of asking?
Most people who commit suicide make contact with a primary care physician within a month of their death.1-2 A lack of knowledge of what signs to look for in patients may contribute to the lack of treatment seen in most people who commit suicide
Based on the literature, it is likely that a significant proportion of dermatological patients are at an increased risk of suicide
It is unlikely that an unplanned suicide attempt can be prevented; however, a planned attempt could be. Suicidal ideation is associated with a significantly increased likelihood of planned suicidal behaviour,3 meaning that an intervention in those at risk, leading to early detection and treatment, could result in a substantial benefit4-6
Those patients that do come forward to seek help with their suicidal thoughts are in the minority, meaning that the dermatological consultation may be a rare opportunity to recognise the signs of suicide ideation and attempt to prevent further suicidal behaviours4-6
1. Luoma JB, et al. Am J Psychiatry. 2002;159(6):
2. Andersen UA, et al. Acta Psychiatr Scand. 2000;102(2):
3. Paykel ES, et al. Br J Psychiatry. 1974;124(0):
4. Picardi A, et al. J Am Acad Dermatol. 2006;54(3):
5. Kessler RC, et al. Arch Gen Psychiatry. 1999;56(7):
6. Wang J, et al. Can J Public Health. 2003;94(3):

15. How to make patients feel safe
Try to speak with the patient alone, as long as they are capable. They may be less likely to discuss these thoughts in front of a family member1
Begin with broader, more open questions, being more specific as the conversation moves forward2
When asking the patient about their thoughts and feelings, maintain an empathic and non-judgmental attitude and tone. This will strengthen the therapeutic relationship and make it less likely that the patient will feel emotions like shame or guilt2
In order to keep the flow of conversation natural and keep the patient at ease, ensure that you are familiar with any screening questions you wish to ask
Gliatto MF, Rai AK. Am Fam Physician. 1999;59(6):
Picardi A, et al. Clin Dermatol. 2013;31(1):47-56.

16. How to communicate
In order to ascertain a patient’s mental state, it is important to ask questions1 1. 2. 3.
When asking patients about suicidal ideation, it can be helpful to begin with a milder or more general question such as
If the patient responds with feelings that concern you, such as hopelessness or loss of interest, inquire further with questions relating to death wishes or depression such as
If the patient’s answers suggest that they have had such thoughts, you should continue with asking them about plans for suicide
How have you been feeling emotionally?
How does life seem at the moment?
Have you ever thought about you would commit suicide?
Have you taken any actions towards killing yourself?
Do you ever wish you could go to sleep and not wake up?
Have you ever felt that your life is not worth living?
1. Picardi A, et al. Clin Dermatol. 2013;31(1):47-56.

17. Tools to assess The Patient Health Questionnaire-91
The Primary Care Screener for Affective Disorders2
Examples of questionnaires that have been validated in dermatological settings
Due to the connection between depression and suicidal ideation, depression screening questionnaires may be a useful means of identifying high-risk patients.
The Columbia-Suicide Severity Rating Scale3
Hospital Anxiety and Depression Scale4
1. Kroenke K, et al. J Gen Intern Med. 2001;16(9):
2. Rogers WH, et al. J Clin Epidemiol. 2002;55(2):
3. Posner K, et al. Am J Psychiatry. 2011;168(12):
4. Zigmond AS, et al. Acta Psychiatr Scand. 1983;67:

18. imminence of that behaviour1
Being at risk or a cry for help
If you feel that a patient shows a risk of suicide, further assessment needs to confirm the
imminence of that behaviour1 1.
Have they made plans?
Detailed and more violent planned methods of suicide, such as using firearms or jumping from a great height, present a greater risk of completed suicide2
If you are not confident about assessing any of these, please refer to a liaison psychiatrist4
If you can confirm that the patient is not at immediate risk and is safe, ensure that they are listened to and feel comforted
Do they fall into any of the high risk categories?2
Severe or chronic illness
Drug/alcohol abuse
Mental health co-morbidities 2.
Family history of mental health disorders
Widowed, divorced or unmarried
Unemployed
Male gender
Adolescent or young adult
Do they have “safe stops”?3 For example:
Religion
Family
Friends 3.
Are they at any immediate risk?
Do they have the means to commit suicide?2 4.
Is the patient safe or can they be made safe?
Inform a family member of your concerns4 5.
1. Galynker I, et al. Psychiatric Annals. 2014;44(9):
2. Picardi A, et al. Clin Dermatol. 2013;31(1):47-56.
3. Dervic K, et al. Am J Psychiatry. 2004;161(12):
4. Gupta MA, Gupta AK. Am J Clin Dermatol. 2003;4(12):

19. Immediate risk
If you think a patient is at immediate risk of suicide: !
It is imperative that the liaison psychiatry team is contacted as well as a family member1*
An emergency psychiatric evaluation must be undertaken
*It should be noted that different countries may have a different protocol. Please refer to your managing body’s advice
1. Gupta MA, Gupta AK. Am J Clin Dermatol. 2003;4(12):

20. Conclusions
Suicide ideation is common among patients with dermatological disease
However, very few patients will be immediately forthcoming when bringing up this topic
Therefore, remember to ask questions and listen to the patient
Discussing these topics openly will put your patient at ease and provide comfort
It allows the patient to have an opportunity to be open and connect with their HCP
Most importantly, it can prevent a psoriasis-related mortality
It is even more common among those patients with psoriasis
HCP, healthcare professional

21. Conclusions
It is important to know how to assess the likelihood of suicide ideation in patients
Identify their risk
Have there been previous attempts?
Have they written suicide notes?
Are they socially isolated?
Have they made any plans for suicide?
Do they suffer from a comorbid affective disease, such as depression?
Have they had recurrent thoughts or considerations surrounding suicide?
It should be noted that the majority of patients will not be at risk
If the risk is not immediate, be sure to continue to monitor them and ensure their safety
If you believe the risk to be imminent then refer the patient to a psychiatrist as soon as possible

22. Just ask

23. Are there any questions?