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Summer 2025
Summer 2025 Issue Shingles’ Psychological Impact Understanding the Long-Lasting Mental Health Implications Herpes zoster, commonly known as shingles, occurs in one in three adults, with an increasing rate of incidence as an individual ages.1 In fact, it is estimated that while the lifetime prevalence of shingles in an adult aged 54 to 59 is only 9.7%, that prevalence rises to 12.7% between the ages of 65 and 69, and 25.8% for individuals aged 90 and older.2 The general public tends to equate shingles with chickenpox, as both are caused by the varicella-zoster virus. Shingles occurs when the virus reactivates in someone who previously had chickenpox. “When we get chickenpox as a kid, the body gets it under control but it [the virus] doesn’t go away,” explains Ian Neel, MD, an associate clinical professor and clinical lead of the geriatric medicine consult service at Senior Behavioral Health at UC San Diego Health, Division of Geriatrics, Gerontology, and Palliative Care. “After years and years, the hold on keeping the zoster virus at bay dampens.” Despite the link, shingles is not chickenpox and manifests differently. Chickenpox, which primarily occurs in children, is usually mild, whereas shingles can be more severe and long-lasting, having an impact that extends well beyond the most common symptoms, particularly for older adults. “It is not just a rash or just the pain,” says Roopa Anmolsingh, MD, lead geriatrician for community programs at the Cleveland Clinic. It’s, instead, an illness that can affect an individual’s physical and mental well-being in both the short and long term. For practitioners working with older adults with shingles, they must understand how it can affect the whole person and the ways in which the illness and the complications that stem from it can take a toll on mental health. Shingles and Its Complications Kenneth Schmader, MD, a professor of medicine at Duke University School of Medicine in Durham, explains that the “shingles pain is not like chronic low back pain or pain when you hurt your arm. It’s pain from a damaged nerve. This has different types of characteristics. Some people will have deep aching, constant burning, or intermittent stabbing pains. Some people will have super sensitive skin where they cannot bear to be touched—allodynia,” he says. “The impact really depends on what kind of pain they’re having and how severe the pain is.” How long the pain will last is also not easily predicted. It may only coincide with the rash or last just a bit longer. This would be the acute phase of shingles. “In some patients,” Schmader explains, “the pain goes on for months and years. That’s the chronic phase.” Chronic nerve pain that lasts beyond the duration of the shingles rash is called postherpetic neuralgia (PHN). It’s the most common complication of shingles and occurs more frequently in older adults than in other populations.3 “It can be really quite severe,” says Barbara Yawn, MD, MSc, FAAFP, an adjunct professor in the department of family and community health at the University of Minnesota. “It can be kind of episodic, but it is a really unpleasant pain—needles and pins or feeling like you got struck by lightning. It can make it impossible to really do much of anything.” Yawn adds that the pain is typically felt where the rash was, meaning it is most common on the trunk or on part of the face. As Schmader states, PHN can last for several months or up to several years. PHN is also not the only potential complication of shingles. In some cases, individuals may have herpes zoster ophthalmicus (HZO), which is shingles that occurs along the ophthalmic branch of the trigeminal nerve. This can lead to issues with the eyes and/or vision. Researchers have found that “HZO can present with a variety of ocular findings, which occur in up to 50% of patients who do not receive antiviral treatment. Depending on the severity of infection, patients may develop significant ptosis secondary to edema, resulting in inability to close the eyelid or dry eye. Red eye, excessive tearing, eye pain, blurred vision, photophobia, and decreased visual acuity are common complaints.”4 Similar to PHN, complications stemming from HZO can last for months if not longer. Additionally, shingles can increase the risk of stroke and cognitive decline. And while rare, some individuals with shingles can develop encephalitis or meningitis, Anmolsingh says, both of which can be life-threatening. Psychological Impact Anxiety can develop before the rash even appears, Yawn says. “Even with short-term shingles, the pain frequently starts before the rash breaks out. That’s cause for anxiety. You’ve got this terrible pain, and you can’t figure out what it is. You go to urgent care, and they can’t find anything. That produces a lot of anxiety,” she says, adding personal experience to her understanding of it. “I had shingles when I was 32, and I had this terrible pain in my ear. It was a week and a half until the rash broke out. Nobody could figure it out until the rash broke out. If someone has that pain on their trunk, [they may worry] am I having a heart attack?” Once the rash does occur, the diagnosis provides an answer as to why the pain occurred, but does not offer many other specific details, such as how severe it will be or how long it will last. “Shingles is one of those diseases where you have no definitive timeline,” Anmolsingh says. “We see anxiety because patients are worried: ‘I’m now five months into shingles, and it’s not getting better. Is this ever going to be better?’” Anxiety can also stem from the unknown impact of complications. For example, with HZO, patients may worry about scarring, having to receive multiple treatments, and other outcomes, Yawn explains. Even once the pain ends, older adults may fear that it will return, not trusting that an illness without a script will ever truly be over. On top of the anxiety is the potential for depression. “Anyone who lives with a chronic pain condition is at a higher risk of developing mental health issues such as depression, anxiety, or suicidality,” Neel says. Schmader adds, “For every one-point increase in pain, there is increasing impact on the likelihood of depression. But it’s more than that. When people are having acute or chronic shingles pain, they just don’t enjoy life.” It becomes harder for individuals to take part in what they were doing prior to the shingles outbreak, whether that’s working, volunteering, helping family members, socializing, and more. The pain and uncertainty can lead to an older adult stepping back and isolating. It can also make activities of daily living harder to complete alone. Dressing or bathing with chronic nerve pain can seem insurmountable to an older adult in this scenario. This can lead to a lesser degree of independence and thus quality of life. “Some people get to the point where they can’t function very well,” Schmader says. “Wham, they get a severe pain syndrome, and now they’re not sleeping, they’re not eating or drinking right. Shingles, specifically severe pain, will interfere with IDLs in a severe way. Who is going to get the groceries? Are they able to drive? Do laundry, housework? Sometimes, it’s catastrophic.” One of the more challenging issues tends to be sleep deprivation, which can be a result of and a contributing factor to mental health issues. The Columbia University Department of Psychiatry notes that “It is now recognized that sleep problems can also contribute to the onset of worsening or different mental health problems, including depression, anxiety, and even suicidal ideation. “Sleep deprivation studies show that otherwise healthy people can experience increased anxiety and distress levels following poor sleep.”5 For an older adult with shingles or shingles complications, lack of sleep can occur because “they’re so anxious that their mind is too busy at night, or they can’t sleep because they don’t have adequate pain relief,” Anmolsingh says. Treatment First and foremost, practitioners will work to address the physical manifestation of shingles. When someone is diagnosed with shingles, they will be given antiviral medications. This mode of treatment is important, but it does not treat the pain that an older adult is feeling. “Antiviral therapy doesn’t necessarily help [the pain] (but everyone should get it),” Schmader says. “For the acute pain, it depends on severity.” Acetaminophen and other pain relievers may be helpful for those with mild pain, while individuals with more severe pain may need something more. However, Schmader cautions, it’s important to consider side effects. “If you’re talking about a 75- or 80-year-old frail individual, the risk of adverse effects is really high. You need a pain management plan.” Yawn agrees, “The medications we have to treat neuropathic pain are not very good. You don’t want to use opioids and trazodone,” she says, because of the side effects and risk of addiction. Another common option is gabapentin, which “also has side effects of nausea and lightheadedness. You don’t want to fall and break your hip!” she notes. Ideally, while determining how best to treat the pain or other symptoms, the practitioner will also begin to address mental health. “It’s important to take a holistic approach with this,” Neel says. “We don’t want to compartmentalize. We don’t want to say, ‘Ok, you’re here to see me for pain with shingles, and that’s it.’ We need to be looking at how this affects the whole patient. [The patient] needs to make sure they’re having conversations with their primary care provider beyond the pain. How is it affecting their life? “As primary care providers, we also need to remember to ask [about mental health]. Addressing both is important because they have a synergistic effect. If we are depressed, our pain will be worse. If we are in pain, our depression will be worse,” he describes. How a patient addresses their anxiety or depression will depend on the individual. Anmolsingh may make one (or more) of several recommendations. “I coach my patients on relaxation therapies. I make sure that they’re not socially isolated and coach them into getting back into their social network,” she says. “I encourage them to stay active and get back into some kind of physical routine. As a last resort, I refer to psychology for cognitive behavioral therapy (CBT).” CBT is proven to be effective for depression and anxiety, and many clinicians—whether working independently or as a part of a health group—are versed in treating patients, particularly older adults, who are also struggling with physical health concerns. Primary care providers, as well as other practitioners like geriatricians, should be prepared to make informed referrals for their patients struggling with mental health, having built a network of trusted providers. “The primary care provider is really meant to be the quarterback,” Neel says, “to help put everything together and contextualize it.” Through both physical and mental health treatment, it is also important that practitioners take note of the caregiver. An older adult with shingles may rely on a partner, child, or other individual for care. With an illness that has no defined length and may significantly impact independence, that can be challenging. “If PHN has crippled this person with severe pain—they can’t shower, they can’t take care of themselves—the caregiver is likely to burn out. If something happens to the caregiver, what happens to the patient? Optimize the caregiver’s health in addition to the patient’s health, whether it’s therapy/counseling, support groups,” Anmolsingh says. Prevention The shingles vaccine is recommended by the CDC for adults 50 years and older, as well as adults 19 years and older with a weakened immune system.6 It is the only way to prevent shingles in an individual who has had chickenpox, and it is proven effective. “The vaccine prevents shingles in individuals between the ages of 50 to 70 and is 95% effective. In people above the age of 70, it is 90% effective,” Schmader says. Despite its efficacy, as of 2018, only 34.5% of adults over age 60 had received the shingles vaccine.7 To encourage patients to overcome their hesitancy, Yawn recommends education and honest conversations. “One of the things that I do and did as a physician is explain [the vaccine to the patient] and ask them what their concerns were and try to address them. The other thing that I go ahead and tell them,” she says, “is look, I had shingles when I was 32. I don’t ever want it again, so yes, I got the vaccine. Yes, my husband got it.” Ideally, with enough information, older adults will seek the preventative care they need. In doing so, they will not only prevent the physical pain of a shingles outbreak but also the psychological toll it can take, as well. — Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.
References 2. Kang H, Ailshire J, Crimmins E. The prevalence of shingles among older adults in the U.S. The Gerontologist. 56(3). 3. Postherpetic neuralgia. Cleveland Clinic website. https://my.clevelandclinic.org/health/diseases/12093-postherpetic-neuralgia. Published October 27, 2021. 4. Lewis K, Palileo B, Pophal C, Yasmeh J, Glendrange R. Herpes zoster ophthalmicus. American Academy of Ophthalmology website. https://www.aao.org/eyenet/article/herpes-zoster-ophthalmicus-pearls. Published January 1, 2020. 5. How sleep deprivation impacts mental health. Columbia University Department of Psychiatry website. https://www.columbiapsychiatry.org/news/how-sleep-deprivation-affects-your-mental-health. Published May 16, 2022. 6. Shingles vaccination. Centers for Disease Control and Prevention website. https://www.cdc.gov/shingles/vaccines/index.html. Published July 19, 2024. 7. Terlizzi EP, Black LI. Shingles vaccination among adults aged 60 and over: United States, 2018. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/products/databriefs/db370.htm. Published July 2020. |
