Systemic agent use and mental health outcomes among patients with psoriasis
Bibliographic record
Abstract
Psoriasis is a chronic immune-mediated skin condition affecting 2.5% of the Canadian population. Moderate-to-severe psoriasis is associated with high risks of depression and anxiety. In randomized controlled trials, biologic agents had better efficacy for skin clearance and anxio-depressive symptom reduction than conventional systemic agents (CSA) in patients with moderate-to-severe psoriasis. However, because of their high acquisition costs, biologic agents are covered by the Quebec public drug plan only if CSA treatment fails or is contraindicated. The goal of my thesis was to assess patterns of CSA and biologic agents (tumor necrosis factor inhibitors and ustekinumab [TNFi/UST]) use and their association with mental health outcomes and costs among patients with psoriasis.In my four manuscripts, I used data from the province of Quebec health administrative databases (1997-2015) and conducted retrospective cohort studies of patients with psoriasis initiating a CSA. In manuscripts 1 and 2, I used the same cohort to describe patterns of CSA and TNFi/UST use and assess sex disparities in factors associated with treatment switch and discontinuation. My cohort included 1,644 patients. In manuscript 1, I examined the CSA as a class. The rates of switch (or add) TNFi/UST and CSA discontinuation were 44.5 and 364.9 per 1,000 person-years, respectively, with no differences between sexes. Older age was associated with a reduced risk of switch in both sexes. Obesity and longer psoriasis duration in males and NSAID use, and adjustment, somatoform and dissociative disorders in females were associated with increased risks of switch, while rheumatoid arthritis was associated with a reduced risk in females. Patients at lower risks of CSA discontinuation were those followed by a rheumatologist and those with an all-cause hospitalization in the previous year among males; and those with rheumatoid arthritis, those receiving hypoglycemic and lipid-lowering agents and those initiated on methotrexate (versus any other CSA) among females. In manuscript 2, I studied each CSA, separately. During follow-up, 312 patients switched to a different systemic agent, with 82.7% receiving another CSA and 17.3% a TNFi/UST.In manuscript 3, I described the trajectories of CSA and TNFi/UST use over a 2-year period and compared depression and anxiety-related health care costs between trajectory clusters. My cohort included 781 patients with no history of anxio-depressive disorders. Using sequence and hierarchical cluster analyses, I identified eight treatment trajectory clusters. The overall predicted mean annual cost per-patient was CAN$ 60. Compared to the cluster persistent methotrexate users, the clusters adding a TNFi/UST (cost ratio 3.63, 95% confidence interval, CI 1.47-5.97) and CSA discontinuation then restart on acitretin or multiple switches between CSA (cost ratio 13.30, 95% CI 5.76-22.47) had higher predicted mean costs. Female (versus male) patients had higher predicted mean costs (cost ratio 1.89, 95% CI 1.11-2.69). Results remained unchanged when adjustment disorder-related costs were also considered.In manuscript 4, I assessed the risk of mental health disorders (depression, anxiety and adjustment disorder) in patients initiated on a CSA who subsequently switched/added TNFi/UST (TNFi/UST users) versus (vs) those who did not (TNFi/UST non-users). TNFi/UST users were included in the cohort at the date of TNFi/UST initiation and TNFi/UST non-users were included at a matched date. I separated the TNFi/UST non-user group into those who were currently using a CSA (current CSA users) and those who were not (previous CSA users). My cohort included 183 TNFi/UST users, 625 current CSA users and 525 previous CSA users. Using marginal structural models, TNFi/UST (vs. previous CSA) users were at lower risk for mental health disorders (HR 0.48, 95% CI 0.28-0.94). The result for TNFi/UST vs current CSA users pointed to a non-significant lower risk
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".