Many people with psoriasis know from personal experience that depression, anxiety and other mental health issues often go hand in hand with this inflammatory disease.
For many years, explains dermatologist and psychologist Rick Fried, M.D., Ph.D., both clinicians and patients thought they understood why.
“People are living with a condition that is often very physically uncomfortable, limits physical activities and intimacy, and can result in sufferers being stigmatized, bullied, and otherwise discriminated against. So, it makes intuitive sense that the potential for anxiety and depression are much higher because of the realities of living with the social and physical burden of the illness,” says Fried, clinical director at Yardley Dermatology Associates and Yardley Clinical Research Associates in Pennsylvania.
Mounting evidence points to an additional reason, a “second hit to the psyche,” Fried says, that underscores how critical it is to get adequate treatment for psoriasis, a disease in which under-treatment is “epidemic.”
Inflammation Is the Culprit
“In people with psoriasis, certain inflammatory cytokines, such as tumor necrosis factor and various interleukins, are elevated; we see a remarkably similar increase in these inflammatory cytokines in depression,” says dermatologist and psychiatrist John Koo, M.D., professor in the Department of Dermatology at the University of California, San Francisco Medical Center.
Cytokines are proteins involved in the inflammatory process of the immune system.
Koo and his colleagues reviewed the raft of evidence for this “cytokine theory of depression” in a 2017 Journal of the European Academy of Dermatology and Venereology (JEADV) article. They concluded that ongoing systemic inflammation likely causes physiologic and biochemical changes that drive the development of depression and other mood disorders.
“These inflammatory cytokines cross the blood-brain barrier,” explains Fried. “In the brain, they send biochemical messages that deplete neurotransmitters such as serotonin, norepinephrine and dopamine, which are intimately involved in our ability to think, to act, to feel, and to function.”
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Treatment Is the Answer
Biologics, which target and block specific inflammatory cytokines, may have a direct biochemical effect on depression.
“By blocking these inflammatory cytokines and calming inflammation, you are changing the cytokine profile for the better – not just in the skin, but in the brain,” says Koo. “In clinical trials of biologics, investigators commonly report that participants with severe psoriasis often experience significant improvements in mood even before you can see any visible difference in their skin.”
A 2015 JEADV review found treatment with biologics significantly decreased depressive symptoms in people with moderate to severe psoriasis. Similarly, a study published in Medicine in 2016 found people with psoriasis experienced lowered rates of depression and insomnia after treating with biologics. Participants also decreased their rate of antidepressant use by 40 Percent after two years.
Therapies such as phototherapy and conventional systemic medications also decrease body-wide inflammation.
“As long as the treatment is adequately treating the person’s psoriasis – so that they have minimal to no symptoms – it should help the mind as well as the body,” says Koo. “When people are treated adequately and aggressively for psoriasis, their depression often goes away.”
Treating “adequately and aggressively” is the goal of NPF’s Treat to Target initiative, which aims to reduce psoriasis to no more than 1 percent of body surface area after three months of treatment. But this goal remains a challenge for far too many.
“Topicals are overused for psoriasis patients, many of whom need potent systemic therapies, not only to treat their skin disease, but also to lower the risk for the many conditions that occur more often in people with untreated chronic inflammation, including diabetes, cardiovascular disease, heart attack, stroke, and obesity, as well as depression,” says Koo.
Koo and Fried advise psoriasis patients who aren’t satisfied with their treatment to discuss more aggressive therapeutic options with their dermatologist. “Many dermatologists are still uncomfortable using biologics despite their effectiveness and safety. If you encounter this, you should seek a second opinion,” says Koo.
“There are safe and effective medications for psoriasis that will make you feel and function better on a day-to-day basis and will decrease the likelihood of some of the real and potentially devastating and life-threatening effects of untreated disease,” Fried adds.
By Emily Delzell for NPF
The emotional side of psoriatic disease can be painful and difficult to talk about. Whether you feel overwhelmed or isolated, need help talking to family about your disease, or would like to get connected with others in your area — the National Psoriasis Foundation can help. Get a free fact sheet on coping with psoriatic disease.