Depression is often linked to psoriasis due to the condition’s uncomfortable and painful symptoms and self-consciousness due to the skin’s appearance. Both of these factors can lead to social isolation, which also contributes to depression. More severe psoriasis has been linked to a higher risk for depression.
Psoriasis is a chronic skin condition that causes skin inflammation, which is usually characterized by thick, red, purple, or pink lesions that have silvery scales. It can occur anywhere on the body, although it is more likely to appear on the torso, scalp, elbow, or knee. The disease is associated with a reduced quality of life.
Research also suggests that depression among people with psoriasis may be partly due to inflammation in the central nervous system as a result from disorders in the immune system that are believed to cause the disease.
MyPsoriasisTeam members frequently share their experiences regarding depression and psoriasis. “It's tough sometimes!” one member said. “I get very depressed when my psoriasis flares where it can't be covered up,” she added. Another member wrote, “I’m not doing very well today. Depression is getting a hold of me again.”
To learn more about the connection between depression and psoriasis, MyPsoriasisTeam spoke with Dr. Alexa Kimball. Dr. Kimball is a professor of dermatology at Harvard Medical School, where she specializes in psoriasis. She is also CEO and president of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center in Boston, Massachusetts.
“Certainly, people recognize the visual effects of psoriasis and the impact of it on others, but probably have underestimated all the ways that it can make people feel,” said Dr. Kimball, noting that depression and anxiety are considered comorbidities of psoriasis.
Studies show varying rates of depression in people with psoriasis. In one study of 90 participants with psoriasis, 79 percent had some form of depression, with 62 percent reporting moderate to severe depression.
According to one study that included more than 4,500 people with psoriasis, major depression that was treated with antidepressants occurred at a rate that was 60 percent higher among people with psoriasis versus those in a control group. In that same study, women with psoriasis were found to be significantly more susceptible to depression treated with medication than men. However, males under the age of 31 had the highest rates of pharmacologically treated depression.
Psoriasis is associated with psychosocial symptoms like low self-esteem and social stigma, both of which can be linked to depression. Psychosocial symptoms are psychological feelings that interfere with social interactions. Self-consciousness, a fear of being touched, and feelings of shame about one’s appearance are some of the common psychosocial symptoms that people with psoriasis may experience. Avoidance of social interaction may lead to feelings of isolation, which can also be linked to depression.
Other depressive symptoms may include:
“I just feel so alone some days,” a MyPsoriasisTeam member said. “I’m surrounded by people, but drowning in isolation.”
Struggles with self-esteem are also a topic of discussion on MyPsoriasisTeam. “My self-esteem is shot,” said a member. Another member wrote about the psychological toll of her experience with developing psoriasis. “In 14 months, I’ve gone from having such confidence and high self-esteem to hating myself, and most days wanting to just curl into a ball and to disappear without anyone noticing,” she said.
“It's the stigmatization that can be very isolating for patients to experience,” Dr. Kimball said, referring to the feeling of being identified as different or unworthy because of psoriasis. She described a study she did on the psychological effects of feeling stigmatized. “We gave medical students a tattoo that looked like psoriasis, and then told them they had to wear it for a weekend,” she explained. “They wore it to the supermarket and they wore it to restaurants. And they came back with a very different perspective of what it was like to have a skin disease, and how that affected how people reacted to you and treated you.”
Dr. Kimball explained that people with psoriasis often make the effort to hide away from people or conceal the condition, either of which can be factors in depression. “Although it is such a common disease, if you don't have it, you don't recognize it,” she said. “I even remember as a medical student, seeing it for the first time and going, ‘How could this affect 3 percent of people, and I've never seen it before?’”
The effort to conceal psoriasis can have a psychological impact that others, including health care providers, may not recognize. “That's part of the disguise element that I think is really a part of the experience for people with psoriasis that's really unfortunate,” Dr. Kimball said.
“There is clearly a strong relationship between depression and psoriasis. They probably also could exacerbate each other,” Dr. Kimball said. She explained that the secondary effects of depression can contribute to disease flare-ups. “People who aren't feeling well about their current state of psoriasis might not be as active. That might make them gain more weight, and that might make your psoriasis worse.” These factors have been shown to be more than psychological and have a direct relationship to the biology of psoriasis.
Depression, stress, and anxiety can cause the release of stress hormones that have been shown to affect the sympathetic nervous system, which is linked to reactions in the skin. Reduced activity or a sedentary lifestyle that may partly be a result of depression can have adverse effects on the body’s metabolic system, which also regulates hormones.
People with psoriasis may have an increased risk for depression due to inflammation caused by immune system disorders that are associated with psoriasis. Psoriasis is believed to be caused by an overactive immune response that causes an overproduction of skin cells.
Immune responses in psoriasis and other autoimmune diseases release inflammatory cytokines (proteins in the immune system). Inflammation from the release of cytokines has been shown to affect neurotransmitters, such as dopamine and serotonin, which regulate mood and are linked to depression and mood disorders.
Biologic drugs that suppress the immune system systemically have been shown to reduce depression by reducing inflammatory responses that affect the brain. The risk of depression has been reduced significantly with biologics, such as Remicade (infliximab) and Stelara (ustekinumab).
Other systemic drugs that have an anti-inflammatory effect and are used in the treatment of psoriasis have been shown to affect depression. Cyclosporine has also been associated with a reduction of depression, while Otrexup (methotrexate) has been linked to a slight increase in psychological distress.
Maintaining your skin care and treatment plan can help reduce flares, which can impact depression. Do not change your treatment plan without medical advice. You can read more about psoriasis treatments here.
“In some of the studies that we did, maybe 10 years ago, we gave people really good treatments, and we measured their depression levels and their anxiety levels as well. You definitely saw them come down with treatment,” said Dr. Kimball. “We can make you feel better just by making your skin clear.”
But Dr. Kimball explained that depression may not always correlate to disease severity or psoriasis symptoms. “What that tells you is there are some elements [of depression] people carry with them even when their skin is clear or almost clear, that probably are going to take a different kind of work or a longer time to resolve,” she said. “So it requires a lot of empathy to figure out how you're going to help people get through that.”
Talk to your dermatologist and health care team if you are feeling depressed. Treatment for depression may include medical or nonmedical approaches that can improve psychological well-being, including:
Self-care and seeking help are key to managing depression. “I honestly believe that if I had never had psoriasis, my anxiety and depression might not even exist,” wrote Jocelyn O’Neil in a recent article posted on the National Psoriasis Foundation website about her experience with drinking and psoriasis. “I cannot change the fact that I have psoriatic disease and, to an extent, its comorbidities, but I can control how I live with it.”
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