QHow do you address isotretinoin in patients that have anxiety?

We are all very familiar with the concern regarding isotretinoin and depression, but how about anxiety? In a society where anxiety has become so prevalent, and is often a comorbidity for our acne patients, it is really important to consider this and counsel appropriately. 

Many studies have been unable to detect association between isotretinoin use and increase in anxiety or depression 1, and some studies have even shown statistically significant decreased scores in anxiety after treatment 1,2,3. 

I personally always start every patient on isotretinoin in a smaller dose, typically 30-40mg/day, to try to “easy them” into the annoying side effects of the drug. If a patient has a history of severe depression or anxiety and is followed by a psychiatrist, I always try to get clearance from their mental healthcare provider before treatment. If they have signs of anxiety I inquire about possible need for therapy and discuss that with the patient prior to initiation. I believe every patient is unique and good communication and documentation is key. I have started patients on isotretinoin on a dose as low as 10mg/day with very close follow up and, even though improvement of the acne was slower, they still achieved completed clearance without any exacerbation of pre-existing psychiatric conditions. 

References:

1. Nikam et.al. Effect of oral isotretinoin on anxiety and depression in patients with acne. J of Pharmacology and Pharamcotherapeutics. 2020;11:113-118.
2. Yessllova et.al. Effects of isotretinoin on obsessive compulsive symptoms, depression and anxiety in patients with acne vulgaris. J of Dermatological Treatment. 2012;23.
3. Ferahbas et.al. A pilot study evaluating anxiety and depressive scores in acne patients treated with isotretinoin. J of Dermatological Treatment. 2004;15.