Biologics for psoriasis also improved mood; measure it

Design

Systematic review and network meta-analysis of RCTs and prospective cohorts

Population

4,319 adults with moderate-to-severe plaque psoriasis in 8 studies

Primary outcome

Change in depression and anxiety symptom scores

Effect

Depression SMD 0.68 (95% CI 0.47 to 0.88) for IL-12/23; anxiety SMD 0.46 for IL-23 and IL-12/23

A BJD systematic review and network meta-analysis pooled eight randomised trials and prospective cohorts involving 4,319 adults with moderate-to-severe plaque psoriasis to compare the effects of biologics on depression and anxiety symptoms.

Every biologic class improved depression and anxiety scores against placebo. For depression, IL-12/23 inhibition had the largest estimate (standardised mean difference 0.68, 95% CI 0.47 to 0.88); for anxiety, IL-23 and IL-12/23 inhibitors were similar (SMD 0.46 for each). Drug-level rankings were uncertain because the networks were sparse and certainty ranged from high to low. Mood generally improved with the skin, but the two did not track in strict proportion.

The practical change is in what counts as a response. If mood improves on treatment, that is part of the benefit, and a patient whose skin has cleared but whose mood has not deserves attention in its own right. These are short-term results, and the class comparisons are not strong enough to choose a biologic for its mental-health effect.

• Record a brief depression and anxiety measure, such as PHQ-9 and GAD-7, before starting a biologic and at review.
• Expect mood to improve with skin clearance, but not always to the same degree.
• Persistent low mood despite clear skin needs its own assessment and referral, not just reassurance.
• Do not choose between biologics on their mood effects alone; the comparisons are too uncertain.
• Ask about suicidal thoughts where depression scores are high.

Why it matters

Mental health is part of what a biologic changes, and leaving it unmeasured misses both benefit and unmet need.

Don't overread it

Differences between biologic classes are uncertain; the review does not show one drug is better for mood.

The statistics, in plain English

A standardised mean difference of about 0.7 is a moderate-to-large effect; 0.46 is moderate. These describe group averages over the short term and do not predict how any one patient will feel.

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