BALANCING MENTAL HEALTH

AND MEDICAL TREATMENT OF

ACNE
SEL 107 45: Research Paper

Natalie Williams
Date: October 4, 2019

To: Professor Krista Sarraf

From: Natalie Williams, SEL 107 45 Composition and Culture

Subject: Research Report: Investigation of “Acne’s Wonder Drug Is a Mental Health Puzzle”

In subject web article Rachel Guttman writes about the acne drug, isotretinoin, and its

possible connection with depression and other mental health side effects. The author focuses on

a new study published in July of 2019 that brings attention to mental health risks of isotretinoin

beyond the previously studied, but inconclusive, links to depression. The author uses the new

study’s findings and reactions to the information, acquired through interviews, to reignite the

pursuit of evidence tying isotretinoin to psychological risks.

In the following report I explore the article’s content and the research found in linked

sources. While the evidence supports continued research into specific links between medication

and any associated side effects, I contend that a partnership of mental health and pharmaceutical

care would be most beneficial in proactively identifying and treating any psychological

conditions associated with acne.

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Introduction

Acne is a skin complaint that can develop into a serious condition. Though not life-

threatening, acne may add to social stigma and a negative view of personal self-image that

changes the patient’s quality of life enough to consider suicide. Acne has been considered an

unwelcome, but often unavoidable, condition of the developing human body primarily

experienced during the teenage years. These years are also more susceptible to changes in

emotions, including negative ones which can progress into feelings of depression or suicidal

thoughts. Isotretinoin is a very effective in clearing the appearance of the skin. Although

beneficial, the medicine has been under scrutiny as a potential contributor to negative mental

health.

Rachel Guttman’s article, “Acne’s Wonder Drug Is a Mental Health Puzzle”, presents her

perspective on the controversary surrounding isotretinoin’s use in the treatment of acne.

Through the introduction of a recently published study and interviews with health and education

professionals, Guttman supports the effectiveness of the drug in the treatment of the skin’s

surface appearance, but also points to the need for additional research on the drug’s potential

mental health risks outside of those already presented to the medical community. Gutman’s

introduction includes the quote, “…Accutane (isotretinoin) poisoned him”; setting the article’s

tone. In Gutman’s closing paragraphs she provides her personal experience with isotretinoin.

She contends that the resulting “acute misery” experienced while taking the drug was not

diagnosed as depression, but offers isotretinoin as a potential cause.

My investigation of the sources driving Gutman’s article leads me to conclude that a

severe acne condition itself merits mental health monitoring. The combination of severe acne
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Natalie Williams
October 4, 2019

and pharmaceutical treatment might demand a collaborative effort to care for both physical and

mental changes.

Literature Review

The Emotional Effect of Acne

In the reviewed literature, all sources agree that acne effects the patient’s emotions. The

societal acceptance of individuals in many ways is based on a concept of beauty. We see the

stereotypical beauty particularly in the media and our daily lives that are classically identified as

having physical features that are pleasing to the eye including flawless, smooth skin. Any

contributor to a less than ideal appearance can cause result in a poor self-image at any age, but

adolescents and teenagers are more susceptible. This age range (10-20) is one of discovery and

change. During this period, hormones levels are increasing causing fluctuations in the body and

the mind. Severe acne can amplify these changes in that there is physical discomfort and a social

one as well. Ayer describes, “The resulting emotional stress of the condition might be more

detrimental than the physical one”. Ng and Schweitzer (2003), Li et al. (2018), and Ayer (2006)

provide perspective on the breadth of these affect that the condition can have on the mind, citing

association with depression, negative self-image, anxiety, self-consciousness, social phobia, and

tendencies toward suicide. Gutman (2019) shares a personal experience with the condition and

the implication of psychological effects while using isotretinoin (Gutman, 2019). Li et al. note

that “It (acne) is the most common skin disease around the world, with an estimated prevalence

of 70% - 80%”. This statistic provides a better understanding of acne’s expansive reach and

potential for emotional insecurity; one might empathize with an individual that seeks effective

relief from acne’s physical and mental discomfort through pharmaceutical treatment.

Isotretinoin provides potential for healing. So why is there so much controversy?

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Isotretinoin’s Effective Use as a Skin Treatment for Acne

Isotretinoin received acceptance for use by the U.S. Food and Drug Administration

(FDA) in 1982, marketed under the brand name Accutane (Guttman, 2019). Just 9 months after

its approval, the drug received attention as the impetus of birth defects. Suuberg (2019) remarks

that in 1985, the FDA required labeling to include risk of depression while using the medication;

in 1998 the advisory expanded, adding the risk of suicide (Ng and Schweitzer, 2003). Currently

the question of the specific causal effect has been ongoing for nearly 4 decades.

While controversary and disagreement among scholars has surrounded isotretinoin since

its approved use for treatment of acne, none dispute its effectiveness in treating acne’s physical

appearance. No other acne medications compare to Isotretinoin. It is the only acne treatment

that counters all four biological mechanism factors of acne making it the most effective treatment

to date with high remission rates (Li et al., 2018; Suuberg, 2019; Ng and Schweitzer, 2003). The

study by Li et al. suggests “…isotretinoin cured around 85% of patients after an average course

of 4 months”. There is agreement that in diminishing the physical appearance of acne, that the

negative emotional effects of the condition will be eased at the same time, lending to the idea of

isotretinoin use balancing any risk of depression with the alleviation of the same through the

clearing of the skin (Li, et al., 2018; Suuberg, 2019; Ayer, 2006).

What makes isotretinoin so effective? It is of the retinoid classification of drugs,

meaning it is a retinoid acid and a derivative of Vitamin A. To simplify the reaction the

medication has on acne, it works, in part, by reducing the production and secretion of sebum (an

oily substance secreted by sebaceous glands); since acne results from the blockage created by

this secretion, the lack of ‘ammunition’ for acne reduces the resulting inflammatory eruptions of

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the skin. However, the retinoid family of drugs also has other effects on the body including those

within the brain (Li et al., 2018; Suuberg, 2019).

Associations Between Isotretinoin and Depression/Suicidal Thoughts

Li et al. (2018) and Suuberg (2019) both discuss the characteristic of retinoid compounds

to cause changes within the brain relating to the altering levels of serotonin, the ‘happy feeling’

chemical. This is theorized to relating feelings of depression. Ng and Schweitzer (2003), Singer

et al. (2019), and Li,et al. (2018) each present correlations to isotretinoin and depression through

the data obtained from prior reported studies. The reported information appears to at least put

the association as possible, if not conclusive. The interesting exception is the Li et al. (2018)

study conclusion that indicates an improvement in symptoms of depression while using

isotretinoin. This stand out analysis does not come without some deficiencies and there is

question in the bearing of the study findings. Additionally, compounding factors were found in

each source article.

FDA Data Used to Determine Depression/Suicidal Thoughts in Published Studies

In determining any association of isotretinoin and depression the authors cite resources

found through the FDA (Singer et al., 2019; Ng and Sweitzer, 2003; Suuberg, 2019). Singer et

al. concentrate their FDA data study on the FDA MedWatch Adverse Event Reporting System

(FAERS). As I contemplated the research in my review, I gained more insight on the program

by visiting the FDA website, fda.gov/. FAERS is a database generator designed for safety

surveillance after a medication has been approved and marketed for use. Adverse reactions to

the medication (events) are logged by both medical professionals and consumers. The frequency

and compilation of the results can initiate updating of product labels, inclusions to the medicine

guide, recall, or changes in design, processing, packaging, or distribution of the drug. This was

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the case in the label changes noted earlier in this review. While the FDA recommended the

changes based on the reports, it is important to note that the reporting by consumers and

professionals is voluntary and there is no clear way to determine if the drug itself is the cause of

the reported effect. Additionally, the reporting is not differentiated enough to eliminate any

duplication of events, where the same incident might be reported by both the professional and

patient. The FDA website does specify that the medications listed on their Potential Signals of

Serious Risks/New Safety Information Identified from the Adverse Event Reporting System

quarterly reports are constructed by the database entries and not an indication of evidence or a

request to discontinue the prescribing of the drug.

The FDA also requires patients using isotretinoin to participate in their iPledge program.

This is a utilized to ensure that patients are aware of the side effects of the drug, most prevalently

on the negative effects on developing fetuses. Though all potential users must participate, the

primary goal is fetal protection. Singer et al. (2019) use iPledge and AERS data to present the

argument that although there is no direct evidence, the reports do provide enough insight to

suggest that patients of isotretinoin are more susceptible to psychiatric issues. Suuberg (2009)

and Ng/Schweitzer (2003) also point to the FDA data to suggest the link of isotretinoin and

depression. While convincing, there is reason to question the suggestions.

Difficulties in Making Conclusions

The literature conclusions are fueled by data studies that have similar shortcomings

preventing the authors from establishing a direct correlation of isotretinoin as a sole contributor

to depression and suicidal thoughts. As previously noted, the FDA AERS-based statistics may

include duplication, cannot be positively identified as an effect of the specific drug reported, and

are submitted voluntarily. Other study characteristics were present that add to the ineffectiveness

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of the result. Retrospective studies, where patients are recollecting an experience are not as

reliable due to any influences of things such as media exposure creating recall bias. Li et al.

(2018) explain that small sample study sizes and a lack of controlled trials limit the authority of

the statistical results.

With the suggestion of acne itself as a contributor to depression, it is difficult to isolate

isotretinoin as being responsible for mental health changes, positive or negative. The

improvement of the condition by any source may balance the negative effect of the treatment

used (Ng and Sweitzer, 2003; Li et al., 2018). Singer et al. (2019) point to placing the suicide

rates reported in context with the elevated rates of the complaints in the entire group of

individuals affected by acne, with or without treatment. According to Singer et al. (2019) “These

data suggest that the rate of completed suicide in patients taking isotretinoin may be lower than

that of the general US population”, further separating isotretinoin as a sole cause of depression.

Li et al. (2019) suggest that controlled studies among acne patients, compiled of users and non-

users, will provide an improved comparison.

Science further complicates scholars’ evaluations. The chemistry of the retinoid drug

category does have an interaction with serotonin levels in the brain, but without the support of

consistent functional brain imaging it would be difficult to determine to what degree the

interaction effects the individual’s emotional state (Suuberg, 2019; Li et al., 2018). Suuberg

focuses on existing mental health conditions and genetics of patients as increasing susceptibility

to psychiatric side effects, which brings and association with isotretinoin, but not as a clear

culprit.

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Summary

I found through this investigation that it is not difficult to see why the controversy over

emotional risks associated with isotretinoin use has remained a conundrum for nearly forty years.

Chemistry delivers one message, study results vary, and the prime target group of acne

(teenagers) is naturally subject to emotional changes. The condition and its cure create a fragile

balance of good versus negative mental and physical comfort. I was not significantly affected by

acne in my youth, but its mild reaction on my skin was no less painful to a socially awkward,

extremely self-conscious teen. I was diagnosed with psoriasis at age 20; I know the physical,

social, and emotional burden compares to severe acne. At times, I secretly wondered if it were

Biblical times would I have been placed in a leper colony.

While isotretinoin carries risk, implied or real, I understand why patients and doctors

elect the drug simply for its effectiveness in erasing the discomfort. The scholars cannot come to

conclusive agreement on this review’s topic; however, since our physical conditions affect our

mental ones, I suggest further focus on mental health as a partner to our pharmaceutical

treatments.

Recommendations and Action Steps

 Readers
As I read Guttman’s article for the first time, the introduction brought a feeling of

sadness for the mother pleading for the justice for her son’s death through a lawsuit

against the makers of Accutane (isotretinoin). This initial response stayed with me

throughout the reading, influencing my interpretation of the remaining paragraphs,

painting isotretinoin as a harbinger of misfortunate mental risks. However, in digging

deeper into the sources behind the article’s content, I found a better understanding of the

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effects of both acne and isotretinoin on mental health. My recommendation for the

reader is to review popular sources with a critical eye to separate the information from

the persuasions of the author. Looking beyond the article, into the sources will guide you

to make your own conclusion. Regarding the specific content of this article, one should

not only examine the potential for side effects of medication, but also pay close attention

to the changes in emotional health, particularly in those of the impressionable and

emotionally fragile teenage years. A partnership of mental health and pharmaceutical

care would be most beneficial in proactively identifying and treating any psychological

conditions associated with acne.

 To the Writer

The persuasive technique in using an emotionally charged opening in the article

was effective in swaying this reader toward a negative view of isotretinoin. However, in

closely reviewing the source behind the content I was left feeling skeptical. I recommend

supporting some areas of the report with more current sources. For instance, the

reference to a “steady stream of research” (Gutman, 2019, par 2) is linked to a study of

data collected from 1996 through 2003. This stale information does not add to the

reader’s confidence in the article’s content.

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Reference List:

Gutman, R. (2019, July 3). Acne’s Wonder Drug Is a Mental-Health Puzzle. Retrieved from The

Atlantic: https://www.theatlantic.com/health/archive/2019/07/isotretinoin-mental-health-

effects-might-go-beyond-suicide/593278/

Singer S, Tkachenko E, Sharma P, Barbieri JS, Mostaghimi A. Psychiatric Adverse Events in

Patients Taking Isotretinoin as Reported in a Food and Drug Administration Database

From 1997 to 2017. JAMA Dermatol. Published online July 03, 2019.

doi:10.1001/jamadermatol.2019.1416

Ng, C., & Schweitzer, I. (2003). The association between depression and isotretinoin use in acne.

Australian and New Zealand Journal of Psychiatry, 37(1), 78-84.

Suuberg, A. (2019). Psychiatric and Developmental Effects of Isotretinoin (Retinoid) Treatment

for Acne Vulgaris. Current Therapeutic Research, 90, 27-31. Retrieved August 2019

Li C, Chen J, Wang W, et al. Use of isotretinoin and risk of depression in patients with acne: a

systematic review and meta-analysis. BMJ Open 2019;9:e021549. doi:10.1136/ bmjopen-

2018-02154

Ayer, J., & Burrows, N. (2006). Acne: more than skin deep. Postgraduate medical journal,

82(970), 500–506. doi:10.1136/pgmj.2006.045377

U. S. Food and Drug Administration, Questions and Answers on FDA’s Adverse Event

Reporting System (FAERS), https://www.fda.gov/drugs/surveillance/questions-and-

answers-fdas-adverse-event-reporting-system-faers

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