Isotretinoin and mental health 

Isotretinoin belongs to a group of drugs called retinoids. It is a highly-effective treatment for:

• severe acne that is resistant to standard antibiotics and topical treatments (medications that are put directly onto the skin)
• acne that is at risk of causing permanent scarring.

Isotretinoin comes as a capsule, and is taken once or twice a day.

In the UK, isotretinoin can only be prescribed by healthcare professionals with expertise in the use of retinoids, or under their supervision. If you are prescribed isotretinoin, you should be told about any potential risks and monitored by your doctor.

Isotretinoin is related to vitamin A. High doses of vitamin A can sometimes cause problems like:

• depression
• tiredness
• irritability
• personality changes.

Because of this there have been concerns that isotretinoin might cause some of these problems.

In this resource we have tried to present the research available on mood changes and isotretinoin. We hope that this information will help you to make decisions about your treatment. However, any decisions you make about your treatment should be based on conversations with your doctor, and your individual circumstances.

Isotretinoin was first approved for the treatment of acne in the 1980s. Millions of people around the world have had their acne treated with isotretinoin without any problems.

However, over the years some people have reported changes in their mood while taking isotretinoin. This suggests that there might be an association between isotretinoin and mental health problems, but it isn’t known for certain if this is the case.

Recent studies of large numbers of people of different ages who were taking isotretinoin did not show an increase in depression or suicide. This was studied by comparing these people with:

• the general population and
• people with acne who were treated with antibiotics.

In fact, suicide is reported more commonly in people with acne who are treated with antibiotics, than in people who are treated with isotretinoin.

The exact frequency of mental health problems in people taking isotretinoin is unknown.

The chance that someone who is taking isotretinoin will experience mood changes is very low. Between 1 in 1,000 and 1 in 10,000 people taking isotretinoin might experience small changes in their mental wellbeing, including:

• tearfulness
• low mood
• anxiety
• agitation.

The chance that someone who is taking isotretinoin will experience more serious mood and behaviour changes is also very low. Less than 1 in 10,000 people taking isotretinoin might:

• experience depression
• behave unusually
• show signs of psychotic illness like losing contact with reality or hearing voices
• have suicidal thoughts
• harm themselves or attempt suicide
• die by suicide.

These feelings and behavioural changes have been reported in people who have had mental health problems in the past, and in people who haven’t. They have happened while people are taking isotretinoin, and after they have stopped taking it.

Some people have reported becoming depressed while taking isotretinoin. In some cases, these people found that their depression improved when the isotretinoin was stopped, and returned when it was restarted. This would suggest that the depression developed because of the isotretinoin. In other cases, these people found that their depression did not return when isotretinoin was restarted.

It is important to understand that depression is a common illness. This makes it hard to say whether people taking isotretinoin who develop depression do so because they are taking isotretinoin, or if it is coincidental.

We know that people with acne are more likely to have anxiety and depression than people without acne. This is the case whether they are taking isotretinoin or not. One of the main reasons for this is that acne and acne scars affect self-esteem and self-confidence. This can lead to low mood, especially in younger people.

There have been several studies showing that isotretinoin can improve negative mood changes caused by acne. Where isotretinoin helps to improve acne, this can have a positive impact on someone’s self-esteem and self-confidence.

There is no evidence to suggest that people with a history of depression are at a higher risk of developing mood changes when taking isotretinoin.

However, while people who have had depression in the past can be treated with isotretinoin, this should be done with caution.

If you have had depression and decide to take isotretinoin, your dermatologist is likely to start you at a low dose and increase it slowly as needed. They will frequently check how you are feeling.

There are reports of people who have bipolar disorder becoming more unwell while taking isotretinoin. If you have bipolar disorder, you might be advised to not take isotretinoin.

A recent study looked at people who attempted suicide whilst taking isotretinoin. It showed that they were more likely to have risk factors such as a personal or family history of mental illness. This makes it difficult to know whether isotretinoin was the direct cause of the problem.

Tell the person treating you if you or anyone in your family have ever experienced any mental health problems. This includes:

• depression
• bipolar disorder
• eating disorders
• anxiety
• self-harm.

You should also let them know if you are under the care of a mental health professional or team.

The person prescribing you isotretinoin may ask you to fill in a mental health questionnaire.

If you have experienced mental health problems in the past, the person prescribing you isotretinoin might ask you to see your GP. By making sure your GP knows that you are thinking of taking isotretinoin, they can:

• help you to decide whether it is safe for you to take isotretinoin
• help to monitor your mood during the treatment
• help you to get any other treatment and support you might need.

• Speak to anyone involved in your care – If you are under the care of a mental health professional or team, you should let them know that you are starting isotretinoin.
• Be aware of any symptoms – Be aware of the symptoms of depression listed below. If you experience any changes to your thoughts, feelings or behaviours, speak to the people who are treating you.
• Speak to your family and friends – It can be useful to tell your family and friends that you are taking isotretinoin and that one of the possible side effects is mood changes. Ask them to let you know if they notice any changes in your mental health so you can report it to the professionals looking after you. 

If you or someone you know thinks your mood or behaviour is changing and you are showing any signs of a mental illness:

• stop the medication immediately
• inform your GP and your dermatology team
• if you are under the care of a mental health service, let them know too.

Some people choose to restart isotretinoin after their mood has improved or if their symptoms of depression are mild. Usually, they would restart isotretinoin at a lower dose.

If you do start isotretinoin again, your dermatologist or GP might refer you to a mental health professional. You might be offered antidepressants or a psychological therapy if you are restarting isotretinoin, as these can help to stop you from becoming depressed again. 

We all feel fed up and sad at times. With depression these feelings don’t go away after a few days and instead carry on and get in the way of life. If you are depressed, you may experience symptoms like:

• feeling unhappy
• losing interest in life
• not being able to enjoy anything
• having trouble concentrating
• finding it harder to cope with challenges
• losing confidence and avoiding social situations
• feeling anxious and on edge
• feeling irritable
• sleeping too much or not enough
• changes in your appetite and weight
• feeling useless and hopeless
• thinking of suicide.

Find out more about depression in adults and depression in children and young people.

If you feel you are at risk of hurting yourself, call 999 or go to your nearest A&E.

If you are not in an emergency but need help, call NHS 111.

If you are under the care of a local mental health service, you can also contact your local support line if you know the number. NHS 111 can also put you in touch with them.

You can also contact the Samaritans, a national organisation that support people in distress or who feel suicidal and need someone to talk to.

Helpline: Freephone 116 123

Website: www.samaritans.org

Other organisations who can help if you are experiencing thoughts of self-harm:

• Campaign Against Living Miserably (CALM) (for men)
  Helpline: 0800 58 58 58
• Papyrus (for people under 35)
  Helpline: 0800 068 41 41
• Childline (for those under 19)
  Helpline: 0800 1111

• Isotretinoin patient information leaflet, British Association of Dermatologists – This leaflet has been written to help you understand more about isotretinoin. It tells you what it is, how it works, how it is used and where you can find out more about it.
• Acne Support – This organisation is run by the British Association of Dermatologists and aims to offer expert, impartial advice on acne.

The Royal College of Psychiatrists has information resources on different mental illnesses and treatments:

• Depression in adults
• Self-harm
• Antidepressants
• Psychotherapies

Information for young people

• Self-harm in young people – for parents and carers
• When bad things happen – for children and young people 

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

This information is adapted from a resource written by Dr Harsha Makena and Dr Jim Bolton from the St Helier Hospital Liaison Psychiatry Service, with support from the Department of Dermatology.

It was reproduced by the Royal College of Psychiatrists in collaboration with the British Association of Dermatologists with the kind permission of Dr Makena and Dr Bolton.

Full references available on request.