Psoriasis is a chronic skin condition at its core—but there’s a lot more happening beneath the surface. Psoriasis—which affects an estimated 7.5 million people in the US—is the result of an overactive immune system, which causes chronic inflammation. While we most often see the effects of this inflammation in the skin, it can also travel to other areas of the body, potentially affecting the nails, eyes, joints, heart, and more.Read on to understand exactly what happens when you have psoriasis, how it might affect your body beyond the skin, and some treatment options that can help.What’s happening with your immune system?When your body needs to respond to an infection, an injury, or a substance that threatens your health in some way (like an allergen), your immune system should kick in to release various cells that fight potentially harmful invaders and protect the body. These cells travel to the affected area and start the healing process, causing inflammation. Here’s the problem: When your immune system is in overdrive, as is the case with any autoimmune condition, including psoriasis, it continues to pump out a large number of inflammatory cells, even when there’s no true threat to the body happening.In people with psoriasis, it’s thought that there’s a faulty immune response that mistakenly identifies healthy skin cells as threatening, which causes the repair system to malfunction. This kicks off an overgrowth of new skin cells, which is what causes the hallmark psoriasis rash. The majority of people with psoriasis have plaque psoriasis, in which the “rash” appears as scaly patches, or plaques, on the skin’s surface.This rash is just one visible sign of inflammation, but a doctor can measure inflammatory markers in your blood, Benjamin Ungar, MD, an assistant professor in the department of dermatology of Icahn School of Medicine at Mount Sinai, tells SELF. People who have psoriasis are more likely to have other autoimmune conditions as well, including certain forms of arthritis and inflammatory bowel disease (IBD). In fact, 25% of people with autoimmune diseases have more than one type—often a skin condition among them, research shows.1And constantly having higher-than-normal levels of inflammation can wreak havoc on everything from your joints to your arteries, potentially leading to confusing body-wide symptoms.Psoriasis and your cardiovascular healthHaving moderate-to-severe psoriasis ups your risk for cardiovascular health issues and metabolic diseases, like high cholesterol and obesity, Dr. Ungar says. While there’s not a clear-cut reason why psoriasis may play a role, research suggests that systemic inflammation in the body is associated with a buildup of plaque and cholesterol in your arteries, which can eventually block healthy blood flow and put you at risk for heart disease.2Because of these potential health risks, it’s a good idea for people with psoriasis to have annual blood pressure and cholesterol readings, and talk with their physician about any family history of heart disease, Samar Gupta, MD rheumatologist and associate professor of medicine at the University of Michigan Medical School, tells SELF. Beyond these checkups, focus on what’s in your control, such as working closely with your care team to find the best treatment for your psoriasis and adopting heart-healthy habits like eating a nutritious diet and exercising regularly in some way, he adds. Getting proper sleep and prioritizing stress-reducing habits are key too.Psoriasis and your jointsAbout 30% of people with psoriasis develop psoriatic arthritis, an inflammatory condition of the joints, tendons, and ligaments, according to the National Psoriasis Foundation. Most people are diagnosed with psoriasis first, though it is possible to develop the symptoms of psoriatic arthritis—such as joint pain, lower back pain, and swelling in fingers, toes, and feet—before psoriasis, says Dr. Gupta.
Not recognizing this shade difference may be why some doctors confuse psoriasis with everyday skin irritation, eczema, a drug reaction, or even an infection in people of color, says Dr. Robinson. But there are other clues that may point to psoriasis.For example, “you can touch the patient and feel that the inflamed area is usually warm,” says Dr. McKinley-Grant. A thorough dermatologist will ask about your family history since the condition can (but not always) have genetic roots, she adds. In case your doc is uncertain, they might also take a small biopsy (a skin sample) and examine it to be sure of the diagnosis and rule out any other skin conditions.2. Rare types of psoriasis tend to be more common in people of color.While plaque psoriasis is the most prevalent form of the condition, “there are also rare subtypes that appear more frequently in certain racial and ethnic groups,” Dr. Robinson says. For example, researchers have found that pustular psoriasis—which appears as inflamed, scaly, pus-filled bumps4—is more common among Asian and Hispanic communities.5Asian people are also more likely to have erythrodermic psoriasis,5 which covers the body in a red, burn-like rash and can be fatal if it’s not treated quickly. What’s more, Asian and Black people tend to be more vulnerable to scalp psoriasis, in which plaques pop up around the scalp, hairline, forehead, back of the neck, and on the skin around the ears.6This is important to know because getting an accurate diagnosis can be complicated if you’re dealing with a form of psoriasis that’s rarer in white people, according to Dr. Robinson, especially if you’re seeing a doctor who’s not experienced in treating darker skin. (You can check out our resources below to help you find a doctor who is well-versed in treating darker skin tones.)3. Certain treatments may not be ideal for your skin color and hair type.While there is still no cure for psoriasis, there are plenty of treatment options to help keep the symptoms at bay, no matter how much melanin is in your skin. These include prescription-strength creams and ointments, phototherapy, oral and injectable medications, and scalp oils and shampoos, among others.However, special considerations need to be made for a few treatments. One, for example, is phototherapy, which involves exposing the skin to a controlled amount of ultraviolet light. “People with darker skin tones require higher doses of phototherapy in order for it to be effective,” Dr. Takeshita says. However, phototherapy can tan the skin and make any unwanted dark spots you have darker, which people of color are especially susceptible to, according to the AAD. If that’s the case for you, standing in a lightbox a couple of times a week may not be the best way to go.For scalp psoriasis, you also need to think about your natural hair texture, how often you prefer to wash it, and how you like to style it, says Dr. Robinson. Frequent shampooing with medicated formulas, which may be recommended in combination with oral medication, can help to remove the scales, but if you have dry hair or washing often doesn’t align with your hair care routine, there are other options out there to help keep your hair as happy as possible.
A psoriasis diagnosis can be overwhelming. Suddenly, you’re told you have a chronic skin condition with no cure—and that’s a lot to take in. So, it’s totally understandable if go through the rest of your doctor’s appointment in a daze. Once you come out of it and process this information, you probably have questions. Like, a lot of questions.While your doctor will probably run through the basics—symptom management, recognizing flares, treatment options—they can’t cover everything in one appointment or even know all of the details you need for your particular lifestyle. That’s why connecting with other people who have psoriasis—about 7.5 million in the U.S., according to the American Academy of Dermatology (AAD)—can be helpful.With that in mind, we spoke to several people living with psoriasis to learn the best questions they’ve asked their doctors—and why their answers were so helpful. Keep these on the back burner for your next doctor’s visit if you’re still navigating the nuances of this disease.1. Can psoriasis affect my health beyond my skin?Fitness and nutrition coach Lauren Scholl was diagnosed with psoriasis when she was 16 years old, and she didn’t fully understand at the time how the condition could impact her overall health.“Everyone suffers from psoriasis differently,” she tells SELF. “I had it on my elbows and ankles and I was like, ‘Nobody notices those things. I’ll live with it.’” But Scholl, now 34, says it wasn’t until she started asking questions that she learned psoriasis could be linked with other symptoms she was experiencing, like joint pain.When she was 28, Scholl was diagnosed with psoriatic arthritis, a chronic inflammatory arthritis that affects roughly 30% of people who have psoriasis.1 “I definitely never would have thought that my skin patches could be linked to joint pain,” she says. “Nobody ever asked me if I had joint pain. If they had, I would have said ‘yes’ and I could have been properly treated sooner than I was.”2. What do I need to know about my type of psoriasis?Sarah Boutwell was diagnosed with psoriasis when she was 12 and psoriatic arthritis when she was 23. Now, at 37, Boutwell tells SELF she’s struggled with symptoms like red, itchy patches on her elbows and knees and smaller red dots on her legs and arms.“I have red spots on 85% of my body most of the time,” Boutwell says. “But now that I’m at an age where I don’t care what people think anymore, I’m no longer afraid to wear shorts and other clothes that show my skin. My skin deserves to see the sun without being judged for my spots.”Boutwell says it’s been helpful for her to find out more about her particular form of psoriasis: guttate psoriasis. (Psoriasis can appear in many forms, including plaque psoriasis, which is the most common type, as well as guttate psoriasis, inverse psoriasis, pustular psoriasis, and erythrodermic psoriasis, all of which have unique symptoms that affect the skin differently.)
According to the Cleveland Clinic, it’s also possible to have overlapping types of psoriatic arthritis, potentially making this disease even more complicated.Back to topWhat does psoriatic arthritis pain feel like?“Often, people with psoriatic arthritis describe generalized feelings of achiness and fatigue before any overt swelling starts,” Rebecca Haberman, MD, a rheumatologist and assistant professor of medicine at NYU Langone Health, tells SELF.The next clue is joint pain or stiffness, swelling, and warmth. Nail changes, lower back pains, swollen fingers or toes, eye inflammation, and foot pain often follow after that.When it comes to the question of how painful psoriatic arthritis is, the answer is that it can vary. For some people it can be mild, and for others, severe. With psoriatic arthritis treatment, you may still experience flares-ups that alternate with periods of remission, according to the Mayo Clinic. As the disease advances, Dr. Haberman says they can see joint damage, which is often irreversible once it develops.Back to topWhere does psoriatic arthritis usually start?“In about 85% of people with psoriatic arthritis, skin psoriasis appears before any joint involvement,” says Dr. Haberman. However, she adds, when it comes to joints, there is no one joint or area where psoriatic arthritis typically starts. “This is different for every person, and a single joint or multiple joints may be involved even at the start,” she says.In addition to having possible joint swelling and pain, Dr. Haberman says people often describe feeling stiff, fatigued, or having more difficulty doing activities that they used to do on a daily basis. “Psoriatic arthritis can also present as back pain and stiffness if it affects the spine or areas of inflammation at the entheses, where ligaments and tendons insert onto the bone, such as the Achilles,” says Dr. Haberman.Back to topWhat organs does psoriatic arthritis affect?Yes, psoriatic arthritis can wreak havoc on your joints and skin, but it can also cause problems in other parts of your body. That’s because psoriatic arthritis causes systemic inflammation—from your eyes to your heart, says Dr. Askanase. It can involve the eyes with uveitis, the gut with inflammatory bowel disease, your heart with early cardiovascular disease, lung inflammation, and liver and kidney problems. “In other words, psoriatic arthritis can be a disease of the whole body,” she says.That said, while psoriatic can increase your risk for these other conditions, it doesn’t mean that you will get them. It’s a good idea to talk with your healthcare team about how to reduce any risk factors you might have, including getting your PsA under control and tweaking your treatment plan, if necessary. These things will help reduce your risk of complications.Back to topDoes psoriatic arthritis show up in blood work?While blood tests are an important factor in supporting a diagnosis of psoriatic arthritis, Dr. Haberman says they cannot alone diagnose psoriatic arthritis. “Psoriatic arthritis is diagnosed by history and physical exam, and often supported by imaging and blood work,” she says.People with psoriatic arthritis may have elevated levels of inflammation in their blood (such as elevated c-reactive protein or erythrocyte sedimentation rate). However, she says these are non-specific markers of inflammation, meaning that any cause of inflammation—not just psoriatic arthritis—can make them elevated.The only way to know for sure if you’re dealing with psoriatic arthritis is to talk with your doctor. They will go through the necessary steps to get a proper diagnosis. If you are diagnosed with psoriatic arthritis, starting on a treatment plan will help manage your symptoms and prevent joint damage, and hopefully get you back to feeling a bit more like yourself.
If all of those check out and you still have a choice to make, consider this: Are you comfortable giving yourself an injection? If so, self-injections take only a few minutes, and you’ll have to do it weekly, every other week, monthly or every few months, depending on the biologic you choose. If you prefer the steady hand of a medical professional, you’ll only have to get infusions once a month to every six months, but the entire process can take a few hours each time.6. How much do biologics cost? Are they covered by insurance?Because biologics are the new, fancy kid on the block, they’re pretty expensive. Three months of biologic maintenance therapy, on average, costs nearly $12,000, according to a 2018 study published in The American Journal of Pharmacy Benefits.3 While doctors have had an easier time getting these drugs covered in the past few years, insurance companies sometimes limit which biologics they’ll cover, or make you prove that you have tried less expensive medicines first, like methotrexate or cyclosporine, both of which are immunosuppressive drugs, says Dr. Milam.If you have insurance and you’re having trouble getting your biologic medication covered, ask your doctor to write a letter of medical necessity to try to convince your insurance company that the drug is truly needed for your situation. If that doesn’t work, it’s worth looking into a medication assistance program. Many pharmaceutical companies offer these to help cover the cost of co-pays, which Moy has used successfully. These plans are sometimes called patient care programs, patient assistance programs, or patient support programs, which are designed to help lower or eliminate the cost of medications for those in need. Other options include prescription savings cards, advocacy groups, and non-profit organizations, all of which may be able to help you with financial assistance.If you don’t have health insurance, you can find Federally Qualified Health Centers that allow you to pay what you can afford for treatment. A few other places to start include: NeedyMeds for a list of available programs; The National Psoriasis Foundation for an overview of available options; and the Medicine Assistance Tool that can help connect you with a patient assistance program.7. How long do I need to take a biologic before I see an improvement?Some biologics, like the IL-17 inhibitors, work very quickly. “Within a few weeks, people might start to notice that their plaques are melting away and they’re starting to feel better,” Dr. Milam says. “But the 12-week mark is when you can expect to see the maximum benefit from most biologics.”When Wollschlager started on a biologic, the results were “almost instantaneous,” and he says he wonders why he wasted so much time covered in ointment. With that said, results can vary from person to person, so be sure to ask your doctor when you should check in if your medication doesn’t seem to be helping.8. How much improvement can I expect?This is where all that agonizing decision-making can pay off. Today’s biologics work so well that most people see significant improvement or even complete skin clearance. More than half of people who take newer generation biologics see 100% skin clearance within five months on the drug, according to a 2020 study published in the International Journal of Molecular Sciences.4
Dr. Ruderman stresses, “That is part of my job as a rheumatologist.” If he doesn’t know what’s important to his patients and what limitations are preventing them from thriving in certain situations, he says, “I won’t know that we need to adjust their therapy to make sure they are able to do those things.”If you are in a work situation that isn’t making adjustments for you, talk to your rheumatologist about your options. They may be able to assist you in asking for a reasonable accommodation. Plus, as Dr. Ruderman says, “the goal of treatment in PsA is to try to avoid the need for such modifications.”Psoriatic arthritis can even impact your relationships.I have definitely tested the “in sickness and in health” portion of my marriage vows. While communication is key in any relationship, that’s especially the case when chronic illness is involved. “People often put others above their own health,” says Dr. Lohr.“Uncertainty about one’s response to a medication and/or potential adverse effects, and having to adapt to a different life can lead to anger, guilt, grief, and frustration,” says Dr. Lohr. And these emotions are not limited to the person with the diagnosis. Chronic illness affects everyone in the family, and I know my husband can also feel cheated by the disease at times.Jeni Lyn, a podcast host from Lima, Ohio tells SELF that just knowing she’s not as physically active or as sexually active as she once was is stressful, and she’s grateful to be in a loving relationship. “Anyone could decide this is too much and they don’t want to be a part of it,” she says, “My husband is my biggest champion. I feel that we’re closer than ever.”Illness can make you feel especially vulnerable. But those hard conversations that happen within an open, trusting relationship are some of the most intimate you will ever have.Mental health matters—especially when you live with psoriatic arthritis. The mental load that accompanies chronic illness and chronic pain is difficult to understand for those who do not experience it. “Pain gets you down,” says Lyn, who tells SELF she’s managed anxiety most of her life but wasn’t expecting prolonged sadness to accompany the pain when she first started living with psoriatic arthritis.“Unfortunately, depression is a very real problem in psoriatic arthritis and rheumatoid arthritis,” says Dr. Ruderman. While it may seem that mental health is best addressed with the help of a different professional, Dr. Ruderman says it’s important to share this information with your rheumatologist, who can factor that into your treatment plan. This doesn’t mean that you can’t also seek out support from a licensed mental health professional or your primary care doctor, but your rheumatologist also might be able to help.“I’ve felt guilty and ashamed because yeah I’m 47 years old and I’m acting like I’m 87, but that’s how old my body feels,” says Lyn. On Sundays when she’s filling up her pillbox for the week, she dreads adding more pills to her daily regimen. “I don’t even want to talk about depression to my providers yet because I don’t want to go on another medication.”Navigating the physical and emotional toll of psoriatic arthritis is a challenge, and each patient will tackle this at whatever pace makes the most sense for them individually. When you have a systemic autoimmune disease, diagnoses can sometimes feel like they’re snowballing, and it takes everything you have to find your balance. If you can, talk to your rheumatologist about all the ways this disease impacts your life. They are not just there for bloodwork and X-rays.“My goal is not to just improve some nebulous measures of disease activity,” says Dr. Ruderman, “But to improve my patient’s ability to function, and to do the things they want to do.”Sources:Journal of the American Academy of Dermatology, Prevalence of Psoriatic Arthritis in Patients With Psoriasis: A Systematic Review and Meta-Analysis of Observational and Clinical StudiesRelated:
“The results from the scan didn’t fit in with any sort of injury, or any sort of wear and tear damage, and with a few other nagging bits in my history, it meant that I was referred straight to the rheumatology team,” Wilson says. Despite inconclusive blood tests, Wilson was diagnosed with rheumatoid arthritis. It wasn’t until she was 28 that she had what she describes as her “largest breakthrough”—she moved to another part of the country and saw a new doctor. “A fresh pair of eyes meant my diagnosis changed to psoriatic arthritis, and with that my treatment changed too,” she says.Unlike Parker, Wilson doesn’t have skin psoriasis, which is possible (though less common) and another factor that may contribute to a delayed diagnosis. In some cases, PsA symptoms may present before the skin symptoms show up, especially in young patients, Dr. Fors Nieves adds. The skin psoriasis may also be present in less visible parts of the body, like the scalp, under the arms, or on the groin or genitals.Psoriatic arthritis treatment is often a case of trial and error.The first hurdle of treatment is typically finding the right specialist, which can be a struggle for some. While Parker’s first rheumatologist wasn’t the right fit, she eventually found a provider she felt comfortable with. “I wanted someone who I could relate to and feel heard,” she says. “I wanted to see someone who understood a person of color may have different experiences with medical staff, and a professional who knew how to communicate with me in a way that was helpful and hopeful.”The next step is finding a treatment method that works for you. In the decade since she first saw a doctor for her joint pain and swelling, Wilson has tried several different treatments with varying levels of success. A few years ago, she underwent arthroscopic surgery to try to reduce some of the inflammation of her knee joint. Wilson says it helped for a while, but it certainly wasn’t a cure. She currently manages her condition with a combination of anti-inflammatory medications, biologic injections, exercise, and sleep.Early and mild PsA is often treated with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. “For some patients, sporadic use of these medications is sufficient to control their symptoms,” Dr. Fors Nieves says. But in more severe cases, and in patients who are experiencing joint damage from the inflammation, stronger medications are often required.“In the case of a patient who is having regular flares with attacks of swollen joints and severe stiffness, we may need to add immunomodulatory medication since PsA is an autoimmune condition,” says Dr. Fors Nieves. These might include conventional disease-modifying antirheumatic drugs (DMARDs), biologics, or enzyme inhibitors.“Some patients may require multiple medicines to have their skin and joint disease under control,” Ronald Yglesias, MD, a rheumatologist in Aventura, Florida, tells SELF.Lifestyle modifications can make a big difference.Managing this condition isn’t just about taking medications—lifestyle changes can actually be life-changing for people with PsA. The key is listening to your body to get an idea of what it needs (or what it really needs a break from). For instance, Wilson started to cut back on alcohol when she realized it was a major trigger for pain and stiffness the next morning.
Like many chronic conditions, psoriatic arthritis (PsA) isn’t something you manage just once. Your psoriatic arthritis treatment journey might be more of a marathon than a sprint, with a few unexpected twists and turns along the way. In fact, nearly half of people with psoriatic arthritis describe the process of finding the right treatment as either somewhat or very difficult, according to an April 2021 survey by SELF and Olson Research Group of 203 people who live with the condition.But keeping your psoriatic arthritis well managed is both possible and crucial. “PsA is an auto-inflammatory destructive musculoskeletal condition,” Ronald Yglesias, MD, a rheumatologist based in Aventura, Florida, tells SELF. “If not treated properly, it can lead to permanent damage of the ligaments, tendons, and joints, which can further progress to chronic pain, osteoarthritis, disability, and a decreased quality of life.”While that may sound intimidating, the good news is that treatment options are out there. In our survey, 32% of people said they were very satisfied with their treatment plan, while another 44% said they were somewhat satisfied. So if you haven’t found the right fit just yet, try not to lose hope.It can take time to find the right medication that works for you, Clifford Stermer, MD, a rheumatologist with Presbyterian Medical Group, tells SELF. In fact, he says he meets with his PsA patients every 90 days until they find a treatment plan that works for them.“Often we try one and need to switch because the medication doesn’t work or isn’t tolerated due to side effects,” he says. “The good news is we have many medications and combinations of medications to use.”If it’s been a while since you spoke with your rheumatologist, or you’re experiencing a flare and wondering if it’s time to rethink your psoriatic arthritis treatment plan, here are some questions to help you figure out if your psoriatic arthritis is well managed—or if it’s time to schedule an appointment to discuss your options.1. Do you have more “bad” symptom days than “good” ones?You’re probably familiar with the main symptoms of psoriatic arthritis: joint pain and stiffness, swollen and painful fingers and toes, limited mobility, and fatigue. Because not everyone experiences psoriatic arthritis the exact same way, the severity of your symptoms and where they happen can vary. But the ultimate treatment goal for people with PsA is low disease activity and, if possible, remission, says Dr. Stermer. To that end, rheumatologists expect to gradually see your unique symptoms improve when you’ve found the right psoriatic arthritis treatment.Everybody with PsA has “good” days and “bad” days, even when the disease is being treated, says Dr. Yglesias. He frequently asks people with PsA about their joint symptoms on a spectrum of severity to determine how well their current treatment is working for them. “As a general guideline, joint symptoms should improve with less joint and back pain, swelling, and stiffness.”2. Is your skin or nail disease flaring up?When you have psoriatic arthritis, managing joint pain and stiffness might be at the top of your to-do list. But skin or nail changes are also something to pay attention to and bring up with your doctor. The experts SELF spoke to agree that psoriatic history is always important, which is why they ask their patients if they’ve had recent skin flares or nail changes.
And then there’s psoriasis—the chronic skin condition that almost always occurs alongside psoriatic arthritis. As SELF previously reported, skin conditions can have a real psychological impact. “People become socially isolated and embarrassed, and there can be a level of disability that comes from skin itching and pain,” Dr. Gupta says. At the same time, any health condition that interferes with your ability to do the things you love to do can lead to feelings of guilt, loss, and frustration.Jen Douglas, PhD, a licensed psychologist in San Francisco and a clinical assistant professor at Stanford School of Medicine, tells SELF that there is a “bidirectional relationship between mental health and physical health.” Meaning that often, when one suffers, so does the other. “This is often referred to as the mind-body connection.”The intriguing role of inflammationWhile it’s not shocking that the experience of living with psoriatic arthritis can exacerbate mental health conditions, there may also be a biological explanation for this association. Experts are investigating the role that inflammation plays in the higher rates of depression among people with chronic inflammatory conditions.“Once we control the inflammation with psoriatic arthritis medication, the patient’s depression often also improves,” Dr. Gupta says. “It’s an association, and we can’t say there’s direct causation,” he notes. While it’s possible this could be a result of symptom improvement, there is growing interest in the role of inflammation in depression. In fact, experts think it could be a two-way street.“We have also found that depression drives skin and joint disease,” says Dr. Gupta. A 2019 research review published in the journal Current Opinion in Rheumatology2 looked at the connection between depression and rheumatoid arthritis, an inflammatory arthritis similar to psoriatic arthritis, and found that depression increases the risk of flares and decreases rates of remission. Similarly, the 2020 Clinical Rheumatology review mentioned earlier found that people with psoriatic arthritis who also had anxiety and/or depression reported greater psoriatic arthritis disease activity.To add to the complexities, living with a mental health condition alongside an autoimmune condition like psoriatic arthritis can make managing either illness even more challenging. “If patients are depressed and anxious, sometimes they are not compliant with medication, making treatment less successful,” says Dr. Gupta.A holistic approach to careThere’s a strong case for working mental health care into your treatment plan for psoriatic arthritis. Many people with the condition already see both a dermatologist and rheumatologist—sometimes even within the same practice, as is the case in Dr. Gupta’s clinic. Adding mental health care into that collaborative, one-stop-shop model would be great, but it’s not something you see very often.Instead, most rheumatologists will refer a patient to their primary care provider or a mental health professional if mental health concerns come up during an appointment. Social anxiety is a big one that Dr. Gupta’s patients mention. “I also always encourage them to get involved in social support groups, because social isolation is one of the big factors that is going to feed depression and anxiety,” he says.