Written by Richard Fried, MD, PhD, as told by Haley Levine
As a dermatologist and psychiatrist, I’ve studied the relationship between mental health and psoriasis for years. Many people do not realize that psoriasis affects only your skin. This condition activates your immune system to attack itself. This can lead to symptoms such as skin discoloration (psoriasis) or joint swelling (psoriatic arthritis). But it can also cause inflammation that we can’t always see. This can lead to other health conditions, such as cardiovascular disease, type 2 diabetes, and even mental health disorders such as anxiety and depression.
It is difficult to know whether psoriasis causes depression or vice versa. Psoriasis is itself fickle. There is no way of knowing when you wake up each morning whether it is a good, bad, or ugly day. The disease seems to do what it wants when it wants. It’s a messy condition: The psoriasis itself often leaves a visible trail of scales and fluid mixed with blood on your body, and psoriatic arthritis can cause physical pain. A lot of times, patients tell me that they never appreciated how bad they felt until they started feeling better.
We think psoriasis itself is caused by a combination of genes and environment. Some people are genetically predisposed to it, and then the shock comes – an insect bite, infection, stress – and your immune system goes into overdrive. The same cytokines, or inflammatory chemicals, that cause symptoms in the skin and joints, also cross the blood-brain barrier and enter the central nervous system. It then acts on the synapses, the junctions of nerve endings and the brain, to reduce levels of brain chemicals such as serotonin, norepinephrine, and dopamine. This, in turn, can lead to mental health conditions such as depression, anxiety, and obsessive-compulsive disorder (OCD).
The good news is that a class of drugs used to treat psoriasis known as biopharmaceuticals also appears to help improve symptoms of depression and anxiety. It makes sense: Biologics work by binding inflammatory cytokines so that they can no longer wreak havoc in your skin, joints, or brain. They can also, of course, help improve mental health as they relieve symptoms of active psoriasis. If your skin improves and your joints become less painful, you will feel more comfortable doing normal activities such as socializing, playing sports, or even going to work.
Recognize the exact signs
Most of us understand the classic symptoms of depression such as low energy, feeling sad or angry, withdrawing from others, or even having trouble sleeping at night. But there are many people with psoriasis who walk around with what in the mental health field we call subclinical depression. You can still go to that party and crack jokes, for example, but under that veneer of affection, you’re just feeling jolly.
Many people with psoriasis are ashamed to admit how they feel. After all, the condition is not cancer. But it still affects their lives in a major way. When I meet patients, I tell them I realize how difficult it is and
Hold eye contact for a few seconds. The majority of them tear up and admit, yes, it can really suck sometimes. Then I asked them what they used to do for fun before they were diagnosed with psoriasis. Often, they admit that they have given up on a lot of the things they used to do. They no longer go out on weekend nights with friends, coach their kids’ softball teams, or volunteer in their communities. They may look fine on the outside, and even think they’re feeling fine mentally, but once they take a quick internal inventory of what they’ve given up on, they realize yes, they are indeed depressed.
How do I get help
General self-care can help a lot. Sometimes people with psoriasis give up. But the more time you spend on your own, the more you focus on symptoms like pain and itching, which will make you feel worse. Tell patients that it is very important that you maintain your regular routine: get up, brush their teeth, take a shower in the morning, get dressed, drink their coffee, and then make sure they have at least one thing to do that day. It may feel like you’re climbing Mount Everest to get out of bed, but you need to. It is also important to ensure that you are in contact with other humans every day. We underestimate how bleak isolation can be.
Exercise is key too, even if your body doesn’t feel like it. I tell my patients that activity begets activity, while inactivity begets inactivity. Any type of rhythmic activity can help, whether it’s walking outside, going for a workout at the gym, or swimming. Our bodies find rhythmic activities very calming. If you’re not really feeling strong enough, even some simple 30-second stretching and deep breathing can help.
If depression persists, seek treatment. A certain type of talk therapy known as cognitive behavioral therapy (CBT) has been shown to work well for people with psoriasis. This type of therapy helps people identify negative thoughts and patterns and helps them reframe them. 2019 review published in the magazine Psychology and behavior management researchFor example, I looked at eight randomized controlled clinical trials and found that CBT relieves not only symptoms of anxiety and depression, but also physical symptoms of psoriasis. It stands to reason that CBT may help reduce some of the overall inflammation caused by the disease.
It is also important not to give up on treatment. If your current regimen is not helping you manage your disease, talk to your doctor. There are now many safe and effective treatments for psoriasis. Twenty years ago, we told patients, “I’m sorry,” and put them in an ultraviolet light box. Now, we know that there are medications that help us to have excellent control of the condition. Once psoriasis is under control, symptoms of depression and anxiety also improve. There is no reason anyone with psoriasis needs to suffer silently in this day and age, either physically or mentally.