Is Psoriasis Linked to Depression?

Psoriasis is a chronic disease that is more than skin deep. In addition to skin and joint involvement, psoriasis is linked to an increased risk of having metabolic syndrome, which includes insulin resistance, obesity, and cardiovascular diseases.^[1] The many comorbidities associated with psoriasis can have detrimental effects on the quality of one’s life. The degree of both physical and emotional impairments in people with psoriasis was found to be similar to those who have diabetes, heart disease, high blood pressure, arthritis, depression, and even cancer.^[2] In fact, people with psoriasis tend to have more mood-related issues such as anxiety, depression, poor self-esteem, sexual dysfunction, and even thoughts of suicide.^[3,4] Over 60% of both men and women with psoriasis have symptoms of depression,^[5] and nearly 80% of people with severe psoriasis believe that psoriasis has negatively impacted their lives.^[6] People with psoriasis can have very severe depression. A clinical study found that approximately 10% of people with psoriasis “desire(s) to be dead” and 5% have active thoughts of suicide.^[7] Clearly, the psychological impact of psoriasis is enormous.

Why Do People with Psoriasis Get depressed?

The link between psoriasis and depression is multifactorial. The answer is not a simple explanation that the appearance of their skin makes them feel sad.^[8] Sometimes the underlying causes of depression in people with psoriasis are not obvious. Several reasons have been reported to make people with psoriasis more prone to having depression:

• Socioeconomics: People with psoriasis tend to have lower employment rates and are less productive at work, resulting in lower income.^[9-11]
• The Worriers’ Vicious Cycle: People with psoriasis can get very anxious and worry about whether their treatments are working. This emotional state has been shown to lower the response rate to their psoriasis treatment, and subsequently makes them even more worried in a cyclical pattern. About two-thirds of people with psoriasis report that their skin flares when they are stressed.^[12]
• Medication Compliance: Depression can affect the willingness of people to comply with using and taking their psoriasis medications.^[13] Older people with psoriasis tend to have an even higher rate of depression and worse compliance with using their topical medications. Furthermore, they are also less likely to use the healthcare resources available to them compared to younger people.^[14] Therefore, elderly people with psoriasis are at increased risk for depression.
• Substance Use: People with psoriasis are more likely to abuse alcohol and smoking, particularly men. Excessive smoking and alcohol consumption has been shown to worsen psoriasis and decrease the efficiency of psoriasis treatments,^[15-17] further contributing to depression and ongoing substance abuse behaviors.
• Social Avoidance: People who have psoriasis, especially during periods of skin flare, tend to be more socially withdrawn.^[18] The lack of social interaction and support can then worsen their depression. 
• Inflammation Induced Depression: Researchers have found that the inflammatory molecules that cause psoriasis, such as tumor necrosis factor, can directly cause depression.^[19,20]

Do People with Severe Psoriasis Get More Depressed?

Not necessarily. Researchers have found that the severity of psoriasis doesn’t always match the level of emotional burden that psoriasis has on a person. Therefore, even people with very mild psoriasis may experience depression.^[3,21,22]

How Do We Treat Both Mind and Body in People with Psoriasis?

Treatment of psoriasis should be multi-faceted, with both medical and psychological care. The impact of mood disorders such as depression can affect how people cooperate and respond to psoriasis treatment. Adding anti-depressant medications to psoriasis regimens can help manage the emotional distress associated with psoriasis. Research has shown that using mood medications alone, without other psoriasis medications, can be useful in treating psoriasis.^[23] 

Combining physical treatment with psychological and behavior management has been shown to be more effective in treating depression than using conventional physical treatment alone. Additionally, more powerful systemic medications can significantly improve skin and joint disease, as well as the depression associated with psoriasis.^[24,25] This makes sense if treatment is decreasing the inflammatory molecules that might directly be causing depression in people with psoriasis.^[19,20]