Why People with Psoriasis Are at Higher Risk of Depression

Much more than just a skin condition, psoriasis can cause feelings of anxiety, embarrassment, and shame that can be overwhelming, at times. Sometimes, people also find themselves with symptoms of a serious mental illness: depression.

Several studies have found that people with psoriasis have a higher risk of depression than people who don’t have the chronic autoimmune disorder—and that applies even if psoriasis symptoms are mild. In fact, according to the National Psoriasis Foundation, people with psoriasis are twice as likely to become depressed as the rest of the population.

A population-based cohort study in the U.K., published in Archives of Dermatology, looked at data collected as part of patients’ electronic medical records from 1987 to 2002. Researchers concluded that people with psoriasis have a higher risk of depression, anxiety, and suicidal ideation.

Another 2015 study published in the British Journal of Dermatology found a “significant” increased risk of depression in American women with psoriasis, even after accounting for age, lifestyle factors, and other chronic conditions.

Potential Causes

Medical professionals don’t know exactly why people with psoriasis are at a higher risk of depression, but they have several possible explanations.

The most obvious relates to what psoriasis does to your skin. Depending on the severity of the disease, the plaques can be difficult to disguise, especially during hot weather when you don’t want to cover up with long sleeves, high necklines, and pants or tights. If your skin is particularly flaky it can be even more embarrassing and hard to hide. The visibility of the condition and the enduring misconceptions—that it’s contagious or caused by poor hygiene or an unhealthy lifestyle—may cause body-image issues and lead to self-imposed isolation, which can be detrimental to mental health, says psycho-dermatologist Alia Ahmed, M.D.

“Having a chronic and unpredictable skin condition can definitely impact mood,” Ahmed adds. “Other negative psychological outcomes include low self-esteem and self-confidence, social anxiety, and poor quality of life.” She says she’s seen that people with psoriasis often find it difficult to express their emotions, so they are more likely to miss opportunities to disclose how they’re feeling. Ultimately, this leads to poor coping and may aggravate psychological distress.

Ahmed’s patients also report problems with sleep, work and/or studies, relationships and intimacy as a result of their psoriasis. “This can also turn into a vicious cycle, where psychological distress aggravates psoriasis and vice versa,” she explains. “Very often, I hear from patients that their psoriasis started after a significant life event like bereavement, a relationship breakdown, losing a job, or moving to a new house.”

Breaking the Cycle

Flora Jennings, 25, says the emotions prompted by living with psoriasis can spin in a vicious cycle. “When I get a flare-up, my self-confidence plummets,” she says. “I don’t want to go out or see friends. But that brings my mood down even further. It’s tough to break.” And because psoriasis is an unpredictable disease, Flora can’t always prepare herself for a flare-up. “It can be triggered by stress,” she says. “But, sometimes, it comes out of the blue, when I least expect it.”

Ahmed agrees that it’s difficult to break the cycle—but it’s not impossible, she says. She encourages people with psoriasis to discuss their skin with healthcare professionals first, to ensure they’re getting the right treatment. “It’s important to disclose the effect skin is having on key quality-of-life aspects like sleep, exercise, relationships, clothing choices, and work or studies,” she adds. “Understanding the impact of psoriasis on the life of the patient is the best way to ensure optimal treatment, and the first step to taking control of the associated mental health aspects.” So, in addition to your physical symptoms, be sure to talk to your doctor about how you’re feeling emotionally. It might be awkward or uncomfortable, but they’re trained professionals who are there to help, not judge.

If mental health issues such as depression still exist despite good medical management for psoriasis, Ahmed says it’s time to consider other options. “Nonpharmacological options include counseling, cognitive behavioral therapy (CBT), acceptance and commitment therapy, and mindfulness. Diet and lifestyle factors also play important roles, so take steps to reduce alcohol intake (booze is a depressant substance), quit smoking, consider healthier food choices, and do more exercise.

“All of these changes can positively impact mental health,” Ahmed says. She also recommends gaining social support by connecting with other psoriasis patients, such as thorough local patient support groups or online communities like Kopa. This also improves knowledge of the condition, which can empower patients to make better decisions about their skin and their mental health.

In some cases, oral meds like antidepressants, antianxiety medications or antipsychotics may be prescribed. “Any mood-managing medications should be checked for interactions with other treatments before being prescribed,” Ahmed says. For example, “Lithium is used to treat people with some types of depression, but this medication is a known trigger for psoriasis—as is alcohol.”

Depression Symptoms and Research

Everyone with psoriasis feels down about their skin sometimes, but if your mood is persistently sad, anxious, or “empty,” you may have depression, per the Anxiety and Depression Association of America. Other common symptoms of depression include feelings of sadness, tearfulness, or hopelessness; loss of interest or pleasure in normal activities like hobbies, sports and sex; sleep problems (like insomnia or sleeping too much); lack of energy; feelings of worthlessness or guilt; trouble concentrating; and, agitation or restlessness.

Research into why people with psoriasis are at a higher risk of depression is still ongoing. A recent theory is that there’s a possible common pathway of psoriasis and depression, where similar chemicals are produced in the body in response to both. When someone has psoriasis, their immune cells release chemicals called cytokines, which make skin cells grow out of control, forming scaly plaques. But that’s not all cytokines do. One particular cytokine, called TNF-alpha, may alter the levels of the brain chemical serotonin, which affects mood and could lead to depression.

The so-called “cytokine theory of depression” was the basis of a review led by dermatologist and psychiatrist John Koo, M.D., from the department of dermatology at the University of California San Francisco Medical Center. After reviewing the available evidence, Koo’s team concluded that ongoing systemic inflammation likely causes the biochemical and physiological changes that spur the development of depression and other mood disorders. Their findings were published in the Journal of the European Academy of Dermatology and Venereology in 2017.

Taking a Multipronged Approach

Life with psoriasis can be extremely difficult, exhausting, and frustrating. The same can be said for life with depression. If you have both, it’s crucial to get the medical care you need—for both conditions—to help you get on the right treatment path.

In Flora’s case, addressing both head-on proved to be a turning point. “I took advantage of everything that was out there: therapy, CBT, and support groups,” she says. “I overhauled my lifestyle, cutting out alcohol and unhealthy food choices and incorporating moderate exercise into my daily routine. I made time for relaxation and made a good night’s sleep a priority.” A year later, Flora feels as if her mental health has improved, and while her psoriasis does flare up during times of stress, she feels like she has more control over her health as a whole.