DOI: https://doi.org/10.53350/pjmhs22164742 ORIGINAL ARTICLE 742 P J M H S Vol. 16, No. 04, APR 2022 Impact of Covid-19 on Mental Health and Treatment Compliance in Psoriasis Patients WAQAR MALIK 1 , WAJIHA MALIK 2 , SADAF MALIK 3 , JAUHAR MUMTAZ KHAN 4 , ZEESHAN HAROON 5 1 Senior Registrar, York teaching hospital, York, UK 2 Assistant Professor, Frontier Medical College, Abbottabad 3 Demonstrator, Frontier Medical College, Abbottabad 4 Consultant Dermatologist, PAF hospital, PAF base Faisal Karachi 5 Assistant professor, Department of Community Medicine, Ayub Medical College, Abbottabad. Corresponding author: Waqar Malik, Email: waqarmalik@nhs.net ABSTRACT Objective: This study was designed to determine the impact of COVID-19 on treatment compliance and mental health (anxiety and depression) in psoriasis patients. Methods: A descriptive cross-sectional study was undertaken in the Department of Dermatology at York teaching Hospital from April to August 2020. One hundred and eleven patients diagnosed with psoriasis were asked to complete a questionnaire (HADS). Patients were also asked about their compliance or self-modifications in their treatment regime due to fear of Covid- 19. Using SPSS version 26.0 all of the collected data was analysed together. Results: 40 patients (36.03%) had depression and 52 patients (46.84%) anxiety on the basis of their HADS score. Twenty patients (18.01%) stopped treatment due to concerns regarding COVID-19. Prevalence of anxiety was more in female patients and those on traditional immuno-suppressants as compared to biological treatment or those receiving topical treatment only. Conclusion: Depression and anxiety are common in patients with psoriasis. Female patients and those on systemic medications are worse affected compared to patients on topical treatment or those receiving phototherapy. Fear of COVID- 19 has led to 18% of patients self-stopping their treatment altogether. Keywords: Psoriasis, Mental Health, Covid-19, Compliance INTRODUCTION Psoriasis is a common chronic inflammatory skin disease . 1 Besides skin manifestations it can be associated with mental health issues like depression and anxiety . 2 The presence of mental health problems is higher in psoriasis patients than in general population. 3 Approximate prevalence of depression in psoriasis ranges from 0 to 58% with the prevalence of anxiety higher than that of depression. 2,3 Covid-19 pandemic has affected the entire humankind. 4 The general population across the globe has changed the way we live and different governments across the world have responded to this pandemic with total or partial lockdowns. 4 Concerns regarding this infection has impacted people’s life and their mental health . 4 With lockdown, liberties and livelihood have been affected and this has resulted in surge of mental health issues generally. 4 The annual incidence of depression in the general adult population is 6.7% and it is reported that to be up to 16.6% of adults can experience depression at least once during their lifetime. 5 Patients with psoriasis can have background mental health issues related to their skin disease 3 but they can be more vulnerable than the general population to develop or to have a deterioration of their pre-existing anxiety and depression with Covid-19 pandemic. 6 Additionally, with lock down there may be concerns regarding accessing the medical services , which can also impact the mental health and treatment compliance . 6 Psoriasis has stronger links with mental health issues than other chronic skin diseases like eczema . 2,3 Psycho- social stress is a known factor that can flare up psoriasis and can also impact the compliance to the treatment. 2,3,6 The exact mechanisms how this impacts the disease is still unclear and is under research 7,8 Postulated mechanisms are related to the proinflammatory cytokines and impact of phyco-social stress on their levels. High levels of pro-inflammatory cytokines impact and alter the metabolism of serotonin and dopamine in the limbic system leading to depression and flareup of psoriasis. 9,10 Anxiety can also impact the flareups of psoriasis and treatment compliance. 6 Again, the exact mechanism how anxiety leads to worsening of the skin is unclear, but possible mechanisms include changes in sympathetic nervous system (SAM) activation due to high amounts of epinephrine and norepinephrine with lower levels of cortisol. 9,11 These changes result in dysregulation of hypothalamus-pituitary-adrenal (HPA) axes 9,11,12 , resulting in changes to pro-inflammatory cytokines number and causing psoriasis flareups. 1,8,9 Psoriasis area and severity index (PASI) score and dermatology life quality index (DLQI) are commonly used to determine the severity of the disease. 13,14 Patients with mild disease receive topical treatment, while patients who have not responded to topical treatment or are in moderate severity group move onto phototherapy as the second line option. 13,15 Patients who are in severe disease category or fail phototherapy move onto systemic traditional immunosuppressants or biological treatment. 13,15 Psoriasis treatment related immune-suppression or perception of the hospitals being high risk areas to visit for phototherapy may lead to increased anxiety and stress in these patients due to fear of COVID-19. 9,16 This can then have an impact on the treatment compliance. 4,9,17 Increased anxiety and stress may also be compounded by the fact that there was relatively little data available about the safety of these treatment modalities at the start of this pandemic. 5,9,18 Additionally, patients may also be anxious or reluctant to move through the psoriasis treatment ladder due to safety concerns or delay the start or switch to more potent agents in the current pandemic. 9,13,14 There is relatively little data available on the impact of COVID-19 on mental health in psoriasis patients. A recent study published from the Czech Republic has shown increased anxiety in patients taking biological treatment compared to those on topical treatment. 6 Keeping in view of the lack of previous studies, we designed this study to determine the impact of Covid-19 on mental health in psoriasis patients . 6 We also wanted to understand and compare this impact amongst patients who were receiving different psoriasis treatment modalities. 5,6,18 In-addition we wanted to see the impact of Covid-related mental health issues on the compliance of the treatment 6 , especially in patients on immunosuppressants or those who had to travel to the hospital every week to receive phototherapy. 17 Patients may perceive psoriasis immune- suppressants risky 6,11 leading to increased stress, anxiety and compliance issues. 5,6 Additionally, patients may be reluctant to travel to the hospitals,to receive phototherapy. 17