woman with depression

Whether you have psoriatic arthritis (PsA) or another type of inflammatory arthritis or chronic disease, here’s essential advice to live by: You need to treat emotional and mental health symptoms as seriously as physical symptoms.

Poor mental health not only interferes with daily living, but it can cause your psoriatic arthritis to flare, increase pain and fatigue, impact your work and relationships, and limit your ability to take your medications properly and manage your overall health.

“Making sure your physical symptoms are taken care of can help ease some burdens mentally,” says CreakyJoints member Eddie A, who has psoriatic arthritis. These symptoms are not existing in a silo where one doesn’t affect the other.” (Learn more about Eddie’s story in The Psoriatic Arthritis Club podcast.)

We talked to experts and patients to help you better understand the link between anxiety, depression, stress, fatigue, and psoriatic arthritis — and what steps you can take to better manage your mental health.

How Psoriatic Arthritis Affects Mental Health

Depression and anxiety are the most common mental health problems that occur in people with inflammatory arthritis, says Susan Bartlett, PhD, a Professor of Medicine at McGill University in Canada. “About one in six people with inflammatory arthritis will have clinically significant levels of anxiety and depression and, in psoriatic arthritis, it’s probably closer to one in three.”

Emotional distress and high levels of anxiety or depression may even be a marker for people who develop psoriasis and PsA, Dr. Bartlett continues. Although more research is needed, we know that “the biological pathways that are implicated with the development of inflammatory arthritis are also many of the same pathways that are implicated with the development of depression,” she explains.

A recent study published in the journal Arthritis Care & Research confirmed that living with PsA can carry a huge mental burden. Study participants with psoriasis and PsA were found to struggle with the following psychosocial areas:

Depression

There’s a strong link between psoriatic arthritis and severe depression, with one study noting that roughly one in five people with psoriatic arthritis may also have mild depression.

This may be related to the disease process itself. People with psoriatic arthritis tend to have high levels of immune system proteins called cytokines, which trigger inflammation and may also contribute to depression. PsA patients may also experience depression because of stigma and embarrassment (about how psoriasis skin symptoms are impacting their appearance) as well as how the disease impacts daily functioning and quality of life.

Anxiety

The unpredictable nature of psoriatic arthritis can certainly cause anxiety. “When you need to be your best — for a wedding, exam, or happy events — the stress can trigger a flare or fatigue — and this can cause anxiety about making plans or going on vacation,” explains Dr. Bartlett.

“Fatigue episodes make me anxious, and I spiral down into depression because I don’t know how long it is going to last, can’t plan social activities, and get concerned about being able to work,” says PsA patient Frances D.

Stress and feeling overwhelmed

Stress is a major trigger for many people living with psoriatic arthritis. It’s a vicious cycle. Having psoriatic arthritis can make you stressed, and in turn, being stressed can make your psoriatic arthritis (and the fatigue that often accompanies it) worse. In one study, more than 70 percent of psoriasis participants cited stressful events as a cause of psoriasis flare-ups.

“For me, any time I’m under stress, or there is a lot going on in my life, my PsA is affected,” says CreakyJoints member Ashley K. “It makes everything harder to accomplish. Getting out of bed, doing chores, or simply just taking care of myself.”

Shame and embarrassment

Unlike many other types of inflammatory arthritis that can be considered “invisible,” psoriatic arthritis can be visible if you have skin plaques or rashes. This can cause additional stigma and fear of being judged, whether at the hairdresser or at the local pool or at school or work, explains Dr. Bartlett.

“My legs and arms and forehead have visible psoriasis, so it’s always embarrassing when you see people staring,” Brittany, who has had PsA for 10 years, told CreakyJoints in an article about embarrassing moments with arthritis.

Disappointment

This disappointment may stem from not being able to do the things you used to love doing, or because you’re not responding to treatment. Unfortunately, PsA is unpredictable. Even if your medications seem to be working, and you’ve been under good control or in remission for some time, you can start experiencing flares and pain that indicate you may need a change in medication for better control.

The Link Between Mental Health and Fatigue

Debilitating fatigue affects roughly 30 to 40 percent of people with psoriatic arthritis (PsA), rheumatologist Alexis Ogdie, MD, Director of the Penn Psoriatic Arthritis Clinic in Philadelphia and Associate Professor of Medicine at the Hospital of the University of Pennsylvania, previously told us in article about the difference between psoriatic arthritis fatigue and being tired.

There are many causes of fatigue, which range from pain and inflammation to medication side effects, lack of sleep, and perhaps not surprisingly, mental health.

A study published in the Journal of Rheumatology linked higher rates of both anxiety and depression in people with PsA to more inflamed joints as well as greater disability and pain — and fatigue.

Depression and anxiety certainly can contribute to fatigue, says Dr. Bartlett. If you’re always tired, can’t get out of bed, or feel too wiped out to do the things you once loved, depression or anxiety can be a big part of that.

If you’re experiencing problematic fatigue, let your doctor know. Chances are, fatigue in psoriatic arthritis is rarely due to just one cause. You and your doctor should discuss the various factors that could be playing a role so you can identify underlying causes and proper treatment. Fatigue that is mainly due to inflammation and disease activity may require a different treatment adjustment than fatigue that is mainly due to anxiety and depression.

Read more about what causes psoriatic arthritis fatigue, and what to do about it.

Understanding the Symptoms of Depression and Anxiety

Anxiety and depression can certainly hit when you’re first diagnosed with PsA, but you may have also wrestled with these conditions prior to your diagnosis. In addition, many people experience anxiety and depression one or two years after diagnosis — “it’s a cumulative effect,” says Dr. Bartlett.

Although anxiety and/or depression is common in psoriatic arthritis and other inflammatory arthritis, it is not normal, nor do you have to just live with it. It’s important to remember that anxiety and depression can be treated. If you’re experiencing any of the below symptoms, talk to your doctor. They may recommend seeing a mental health professional who can guide you on coping strategies, lifestyle changes, and/or medications to help.

Symptoms of depression:

  • Anxiety
  • Feelings of sadness or irritation
  • Emptiness, hopelessness, or worthlessness
  • Fatigue or decreased energy
  • Trouble concentrating, remembering, and making decisions
  • Having irregular sleep patterns, either from not being able to sleep or sleeping too much
  • Changes in your diet, such as either eating too much or too little
  • Thoughts of death or suicide (or suicide attempts)
  • Aches, pains, cramps, headaches, or digestive problems without a clear physical cause that don’t get better with treatment

Symptoms of anxiety:

  • Anxious thoughts or beliefs that are hard to control
  • Feeling restless and tense
  • Being easily fatigued
  • Pounding or rapid heartbeat
  • Unexplained muscle aches or tension
  • Dizziness
  • Shortness of breath
  • Sleep problems (trouble falling or staying asleep)
  • Avoidance of everyday activities

How Mental Health Affects Psoriatic Arthritis Management

When you’re emotionally wiped out, you have less energy for following lifestyle habits that contribute to your overall health, like getting regular physical activity and preparing healthy meals. This, in turn, can increase your fatigue and decrease your ability to manage your psoriatic arthritis, explains rheumatologist Eric Ruderman, MD, a Professor of Medicine at Northwestern University.

In addition, there’s a strong link between depression and medication non-adherence, or not following the treatment plan your doctor has prescribed.

“Depression is one of the best markers of non-adherence to treatment,” says Dr. Bartlett. “People who are depressed are far less likely to be taking their treatment as prescribed. Part of that is due to the sense of hopelessness and helplessness that’s very much a part of depression.”

Treatment and Coping Strategies

Managing your mental health will likely require a well-rounded approach that may include therapy, medication, and healthy lifestyle habits.

Consider therapy

Even a short bout of therapy, say eight to 12 weeks, can help you understand your thought patterns and behaviors, says Dr. Bartlett, who recommends talking to a mental health professional or counselor from your religious group who is trained in treating mental illness.

Another route: a cognitive behavioral therapy app that can help you examine your thought patterns and behaviors and give you skills to take back power over your disease. Dr. Bartlett’s recommendations: Calm, Mindshift, and iBreathe.

Discuss medications

There are a number of different anti-anxiety medications and antidepressants available. The right medication for you depends on the severity of your condition and whether you have other health problems or take other medications.

“There are effective treatments for both anxiety and depression,” says Dr. Bartlett. “One of the most courageous things you can do is to ask for help.” Get tips for talking to your doctor about your mental health.

Get moving

Exercise is often a first-line treatment for mild to moderate depression. Exercising outdoors is even better because you’ll get some mood-boosting vitamin D from being in sunlight, says Dr. Bartlett. Talk to your doctor before starting an exercise program to avoid injury and find a routine that’s right for your fitness levels and energy. Walking outside for 15 to 30 minutes a day (or even less, at first) is a great place to start.

Catch your inner dialogue

It’s normal for people with inflammatory arthritis, or any type of chronic illness, to catastrophize their pain, which can exacerbate feelings of helplessness, says Dr. Bartlett.

Catastrophizing is dwelling on how much your body hurts or how helpless you feel against the pain, which often leads to worst-case scenario-type thinking. This type of mindset can keep you stuck in depression.

Here are some examples of catastrophizing, according to Dr. Bartlett:

  • What if I never feel better; how am I going to be a good father or mother to my kids?
  • What If I never feel good; how will I feel in five or 10 years?
  • What if I lose my job; what if I’m never able to work again?

Although learning to stop this response won’t stop the pain, it can help you to better cope with your emotions and manage your condition. Seeing a mental health professional can help you recognize catastrophizing or other kinds of toxic inner dialogue and develop strategies to reframe your thoughts.

Eat a balanced diet

There’s a reason people turn to comfort food when they feel depressed and anxious, but high-sugar, high-sodium processed snacks and sweets may increase inflammation in the body. While there’s no such thing as a diet specifically for psoriatic arthritis, snacking on whole foods that are packed with nutrients — think fruits and vegetables, whole grains, and nuts — can help to manage your weight, minimize inflammation, and boost your energy. Get more tips on how to eat healthier with psoriatic arthritis.

Seek support from the PsA patient community

Emotionally, psoriatic arthritis can make you feel isolated and misunderstood, particularly if you don’t know anyone with PsA or other similar conditions. This is why it’s important to reach out to others and join an online or in-person support group made up of those who know exactly what you’re going through.

“Support from other PsA patients has helped me not feel alone and full of despair,” says Frances D.

You can ask your doctor about local support groups (there may be ones run through a local hospital or health care system), or look up groups online (like on Facebook).

You can follow CreakyJoints on social media — Facebook, Instagram, Twitter, Tik Tok, YouTube — to connect with other patients who are seeking community for living with arthritis and other chronic illness.

Fake it until you make it

Even if you’re not in the mood, try pushing yourself to do things that once brought you pleasure, says Dr. Bartlett, paraphrasing the well-known quote: “It’s a lot easier to behave yourself into a new way of thinking than to think yourself into a new way of behaving.” Get up and go for that walk or get yourself dressed and meet a loved one in the park.

Managing anxiety, depression, fatigue, and other mental health issues on top of an already challenging conditions like psoriatic arthritis is not easy — but it is essential and acknowledging that it’s necessary is a great first step. “The mind-body connection is so important,” says Ashley K. “Many people don’t realize how much emotions can affect the body.”

There are no quick fixes or easy answers, but you can take comfort knowing that your health care providers and the greater chronic illness community are there to help along the way.

Get Mental Health Support

We understand how difficult it can be to cope during these uncertain times, especially when you are living with chronic illness. It is important to talk to someone who can help. You should contact your primary care physician or your insurance provider to learn about the supportive resources that are available to you. Here are other mental health resources for your reference:

Cohen BE, et al. Psoriasis and the risk of depression in the US population: national health and nutrition examination survey 2009-2012. JAMA Dermatology. January 2016. doi: https://doi.org/10.1001/jamadermatol.2015.3605.

Interview with Eric Ruderman, MD, a rheumatologist at Northwestern University

Interview with Susan Bartlett, PhD, a professor of medicine at McGill University in Canada

Koo J, et al. Depression and suicidality in psoriasis: review of the literature including the cytokine theory of depression. Journal of the European Academy of Dermatology and Venereology. July 2017. doi: https://doi.org/10.1111/jdv.14460.

Zhao SS, et al. Systematic review of mental health comorbidities in psoriatic arthritis. Clinical Rheumatology. January 2020. doi: https://doi.org/10.1007/s10067-019-04734-8.

McDonough E, et al. Depression and anxiety in psoriatic disease: prevalence and associated factors. Journal of Rheumatology. May 2014. doi: https://doi.org/10.3899/jrheum.130797.

National Institute on Mental Health. Anxiety disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders#part_2223.

National Institute on Mental Health. Mental health medications. https://www.nimh.nih.gov/health/topics/mental-health-medications#part_2359.

Sumpton D, et al. Patients’ perspectives and experience of psoriasis and psoriatic arthritis: a systematic review and thematic synthesis of qualitative studies. Arthritis Care & Research. March 2019. doi: https://doi.org/10.1002/acr.23896.

Xhaja A, et al. An epidemiological study on trigger factors and quality of life in psoriatic patients. Mater Sociomed. Materia Socio-Medica. June 2014. doi: 10.5455/msm.2014.26.168-171.