Acne, depression, and suicide

Both adolescents and acne patients have significant psychologic problems, including depression. There is no formal epidemiologic evidence from either treatment cohort studies or large-scale population studies for an association between isotretinoin use and depression. There is, however, case report evidence that isotretinoin may be associated with the development of depression. Cases showing positive dechallenge and rechallenge are important in pointing to an individual susceptibility. There should be further rigorously designed cohort and population-based epidemiologic studies, however, of this possible connection. Such studies should include a focus on possible contributing factors and pre-existing conditions. In 2004, there were about 70 lawsuits in the United States alleging that isotretinoin had caused patients injury, including suicide, depression, birth defects, and gastrointestinal injuries [80]. Although such lawsuits may reveal much about the inner conflicts within a major pharmaceutical company concerning adverse effect disclosure, it is unlikely that they provide new and credible information about the relationship between isotretinoin and these adverse events. It is possible that public and political pressure will force the withdrawal of isotretinoin, at least from the United States markets. Such a move would deprive many thousands of patients with severe acne from benefiting from the unchallenged efficacy of the drug. It might also spawn an illicit market for isotretinoin, lacking the control of informed and concerned physicians. Patients and their relatives must be informed about the occasional occurrence of depression in patients on isotretinoin and they should be encouraged to report depressive symptoms promptly. At each visit, the physician should inquire specifically about symptoms of depression and, if necessary, antidepressant treatment, referral to a psychiatrist, or discontinuation of isotretinoin should be considered.