By Richard Fried, MD, PhD, as reported to Hallie Levine
As a dermatologist and psychologist, I have studied the connection between mental health and psoriasis for years. Many people don’t realize that psoriasis affects more than just your skin. This condition activates your own 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 problems like cardiovascular disease, type 2 diabetes, and even mental disorders like anxiety and depression.
It is difficult to find out whether psoriasis causes depression or vice versa. Psoriasis disease is capricious itself. There’s no way to tell when you wake up in the morning whether it’s going to be a good, bad, or ugly day. The disease seems to do what it wants, when it wants. It’s a messy condition: Psoriasis itself often leaves a visible trail of scales and bloody fluids on your body, and psoriatic arthritis can cause physical pain. Patients often tell me they never appreciated how bad the illness felt until they felt better.
We believe that the psoriasis disease itself is caused by a mix of genes and environment. Some people are just genetically predisposed to it, then trauma – an insect bite, infection or stress – kicks in and your immune system kicks into high gear. The same cytokines, or inflammatory chemicals, that cause symptoms in your skin and joints also cross the blood-brain barrier and enter your central nervous system. They then act on your synapses, the connections between your nerve endings and your brain, to reduce levels of brain chemicals like serotonin, norepinephrine, and dopamine. This, in turn, can trigger mental illnesses such as depression, anxiety, and obsessive-compulsive disorder (OCD).
The good news is that a class of drugs used to treat psoriasis, known as biologics, also appear to help improve symptoms of depression and anxiety. It makes sense: biologics work by binding inflammatory cytokines so they can no longer wreak havoc in your skin, joints, or brain. Of course, they can also help improve mental health by relieving the symptoms of active psoriasis. When your skin improves and your joints are less painful, you’ll feel more comfortable in normal activities like socializing, exercising, or even going to work.
Most of us are familiar with the classic symptoms of depression such as lack of energy, feeling sad or angry, withdrawing from others, or even having trouble falling asleep at night. But there are many people with psoriasis walking around with what we in the mental health field call subclinical depression. You can still go to that party and tell jokes, for example, but underneath that facade of friendliness you just feel blah.
Many people with psoriasis are ashamed to admit their feelings. After all, it’s not cancer. But it still has a big impact on her life. When I meet with patients, I tell them I know how hard it is and…
Maintain eye contact for a few seconds. Most of them tear up and admit that sometimes it can really suck. Then I ask them what they used to do for fun before they were diagnosed with psoriasis. They often admit that they have given up a whole lot of things they used to do. They no longer go out with friends on the weekends, coach their children’s softball teams, or volunteer in their communities. They may look good on the outside and even think they feel good mentally, but once they take a quick internal inventory of what they’ve given up, they realize that they are actually depressed.
General self-care can help a lot. Sometimes people with psoriasis just give up. But the more time you spend alone, the more you can focus on symptoms like pain and itching, which will make you feel worse. I tell patients it’s so important to stick to their usual daily routine: get up, brush your teeth, shower in the morning, get dressed, drink coffee, and then make sure they have at least one thing to do that day. It may feel like climbing Mount Everest to get out of bed, but you have to do it. It’s also important to make sure you’re interacting with other people every day. We underestimate how depressing isolation can be.
Exercise is also key, even if your body doesn’t feel like it. I tell my patients that activity breeds activity while lethargy breeds lethargy. Any type of rhythmic activity, whether it’s walking outside, going on the elliptical at your gym, or swimming, can help. Our body finds rhythmic activity very calming. If you really don’t feel strong enough, even some simple 30-second stretches and deep breathing can help.
If depression persists, seek therapy. A specific form of talk therapy known as cognitive behavioral therapy (CBT) has been shown to work very well for people with psoriasis. This type of therapy helps people identify and reframe negative thoughts and patterns. A review of 2019 published in the magazine Psychology research and behavior management, for example, examined eight randomized controlled clinical trials and found that CBT not only relieved symptoms of anxiety and depression, but also physical symptoms of psoriasis. It makes sense since CBT may help reduce some of the overall inflammation caused by the disease.
It is also important not to abandon treatment. If your current therapy isn’t helping you manage your illness, talk to your doctor. There are now so many safe and effective therapies for psoriasis disease. 20 years ago we would simply tell patients “I’m sorry” and put them in a UV light box. Now we know that there are medications that help us gain excellent control over the condition. Once psoriasis is under control, symptoms of depression and anxiety usually improve as well. There is no reason why someone with psoriasis disease has to suffer in silence these days, either physically or mentally.