By Richard Fried, MD, PhD, as told to Hallie Levine
As both a dermatologist and psychologist, I have studied the relationship between mental health and psoriatic disease for years. Many people don’t realize psoriatic disease 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 conditions, such as cardiovascular disease, type 2 diabetes, and even mental health disorders such as anxiety and depression.
It’s hard to tease out whether psoriatic disease causes depression, or vice versa. Psoriatic disease is itself capricious. There’s no way to tell when you wake up each morning whether it will be a good, bad, or ugly day. The disease seemingly does what it wants, when it wants. It’s a messy condition: Psoriasis itself often leaves a visible path of scales and blood-tinged fluids on your body, and psoriatic arthritis can cause physical pain. Oftentimes, patients will tell me that they never appreciated how bad the disease felt until they start to feel better.
The Brain-Inflammation Connection
We think psoriatic disease itself is triggered by a mix of genes and environment. Some people are just genetically predisposed to it, then a trauma comes along — a bug bite, or an infection, or stress — and your immune system goes into overdrive. 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 junctions of your nerve endings and brain, to reduce levels of brain chemicals such as serotonin, norepinephrine, and dopamine. This in turn can trigger mental health conditions such as depression, anxiety, and obsessive-compulsive disorder (OCD).
The good news is that a class of drugs that is used to treat psoriatic disease known as biologics also seems to help improve symptoms of depression and anxiety. It makes sense: Biologics work by binding up inflammatory cytokines so that they can no longer wreak havoc in your skin, joints, or in your brain. They also, of course, can help improve mental health because they relieve symptoms of active psoriatic disease. If your skin improves and your joints hurt less, you feel more comfortable doing normal activities such as socializing, exercising, or even going to work.
Recognizing the Subtle Signs
Most of us understand the classic symptoms of depression such as low energy, feeling sad or angry, withdrawal from others, or even trouble going to sleep at night. But there are many people with psoriatic disease who walk around with what we in the mental health field call subclinical depression. You may still go to that party and tell jokes, for example, but underneath that veneer of affability, you just feel blah.
A lot of people with psoriatic disease are ashamed to admit how they feel. After all, the condition isn’t cancer. But it still impacts their life in a major way. When I meet with patients, I tell them I realize how tough it is and
hold eye contact for a few seconds. The majority of them tear up and admit that yes, it can really suck sometimes. I then ask them what they used to do for fun before they were diagnosed with psoriatic disease. Oftentimes, they admit that they’ve given up on a whole lot of things they used to do. They no longer go out on weekend nights with friends, or coach their kids’ softball teams, or volunteer out in their communities. They may look OK on the outside, and even think that mentally, they feel OK, but once they’ve taken a quick internal inventory of what they’ve given up, they realize that yes, they are indeed depressed.
How to Get Help
General self-care can help a lot. People with psoriatic disease sometimes 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 keep on your regular routine: Wake up, brush their teeth, take a morning shower, get dressed, drink their coffee, and then make sure that they have at least one thing to do that day. It may feel like climbing Mount Everest to get out of bed, but you need to. It’s also important to make sure that you have contact with other human beings each 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 begets activity, while lethargy begets lethargy. Any sort of rhythmic activity, whether it’s walking outside, going on the elliptical in your gym, or swimming, can help. Our bodies find rhythmic activities very soothing. If you really don’t feel strong enough, even some simple 30-second stretches and deep breathing can help.
If depression persists, seek out therapy. A particular type of talk therapy known as cognitive behavior therapy (CBT) has proven to work very well for people with psoriatic disease. This type of therapy helps people identify negative thoughts and patterns and helps them reframe them. A 2019 review published in the journal Psychology Research and Behavior Management, for example, looked at eight randomized controlled clinical trials and found that CBT not only relieved symptoms of anxiety and depression, but also physical symptoms of psoriatic disease as well. It makes sense, as CBT may help decrease some of the overall inflammation caused by the disease.
It’s 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 so many safe, effective therapies out there now for psoriatic disease. Twenty years ago, we just said to patients, “I’m sorry” and stuck them in a UV light box. Now, we know there are medications to help us gain excellent control over the condition. Once psoriatic disease is under control, symptoms of depression and anxiety usually also improve, too. There’s no reason any person with psoriatic disease needs to suffer in silence in this day and age, either physically or mentally.