Nonadherence to systemic immune-modifying therapy in people with psoriasis during the COVID-19 pandemic: findings from a global cross-sectional survey
Authors: Quirke-McFarlane Sophia , Weinman John , Cook Emma S , Yiu Zenas Z N , Dand Nick , Langan Sinead M , Bechman Katie , Tsakok Teresa , Mason Kayleigh J , McAteer Helen , Meynell Freya , Coker Bolaji , Vincent Alexandra , Urmston Dominic , Vesty Amber , Kelly Jade , Lancelot Camille , Moorhead Lucy , Barbosa Ines A , Bachelez Herve , Capon Francesca , Contreras Claudia R , De La Cruz Claudia , Di Meglio Paola , Gisondi Paolo , Jullien Denis , Lambert Jo , Naldi Luigi , Puig Lluís , Spuls Phyllis , Torres Tiago , Warren Richard B , Waweru Hoseah , Galloway James B , Griffiths Christopher E M , Barker Jonathan N , Norton Sam , Smith Catherine H , Mahil Satveer K ,   the PsoProtect study group, Alfailakawi Haleema , Alwan Wisam , Ejarque Rosa Andres , Barbosa Ines , Diz Carmen Bugarin , Grys Katarzyna , El Sayed Mahira Hamdy , Truong Tran Hong , Okuse Masanori , Samselska Dagmara , Tosi Isabella , Wang Ya-Hsin 
Published: January 2023

Abstract

Background
Nonadherence to immune-modifying therapy is a complex behaviour which, before the COVID-19 pandemic, was shown to be associated with mental health disorders in people with immune-mediated diseases. The COVID-19 pandemic has led to a rise in the global prevalence of anxiety and depression, and limited data exist on the association between mental health and nonadherence to immune-modifying therapy during the pandemic.

Objectives
To assess the extent of and reasons underlying nonadherence to systemic immune-modifying therapy during the COVID-19 pandemic in individuals with psoriasis, and the association between mental health and nonadherence.

Methods
Online self-report surveys (PsoProtectMe), including validated screens for anxiety and depression, were completed globally during the first year of the pandemic. We assessed the association between anxiety or depression and nonadherence to systemic immune-modifying therapy using binomial logistic regression, adjusting for potential cofounders (age, sex, ethnicity, comorbidity) and country of residence.

Results
Of 3980 participants from 77 countries, 1611 (40.5%) were prescribed a systemic immune-modifying therapy. Of these, 408 (25.3%) reported nonadherence during the pandemic, most commonly due to concerns about their immunity. In the unadjusted model, a positive anxiety screen was associated with nonadherence to systemic immune-modifying therapy [odds ratio (OR) 1.37, 95% confidence interval (CI) 1.07–1.76]. Specifically, anxiety was associated with nonadherence to targeted therapy (OR 1.41, 95% CI 1.01–1.96) but not standard systemic therapy (OR 1.16, 95% CI 0.81–1.67). In the adjusted model, although the directions of the effects remained, anxiety was not significantly associated with nonadherence to overall systemic (OR 1.20, 95% CI 0.92–1.56) or targeted (OR 1.33, 95% CI 0.94–1.89) immune-modifying therapy. A positive depression screen was not strongly associated with nonadherence to systemic immune-modifying therapy in the unadjusted (OR 1.22, 95% CI 0.94–1.57) or adjusted models (OR 1.14, 95% CI 0.87–1.49).

Conclusions
These data indicate substantial nonadherence to immune-modifying therapy in people with psoriasis during the pandemic, with attenuation of the association with mental health after adjusting for confounders. Future research in larger populations should further explore pandemic-specific drivers of treatment nonadherence. Clear communication of the reassuring findings from population-based research regarding immune-modifying therapy-associated adverse COVID-19 risks to people with psoriasis is essential, to optimize adherence and disease outcomes.