The following is an excerpt from Pearls in Psoriasis with Dr Lawrence Green, featuring Dr April Armstrong and her study on patient mental health and satisfaction with their physicians.
Dr Green: April, how did you determine the differences between psychological distress and depression? Because it seems to me that there’s a lot of overlap between the two. How is that measured in your study?
Dr Armstrong: Thanks for that question, Larry. As you alluded to, there is some overlap between psychological distress and symptoms of depression. So, the study1 used essentially a validated measure for those terms.
To measure psychological distress, the study used something called Kessler [Psychological Distress Scale-6], which asks patients how often they have felt during the last 30 days some of the following qualities, for example, nervousness, hopelessness, restlessness or fidgety, and feeling that nothing could cheer them up and that everything was an effort. Then, finally, the degree that they felt that they may be worthless. So, this is the psychological distress measure that those domains are the ones that particular measure focused on.
Now, for symptoms of depression, obviously, there are some overlap. The [Patient Health Questionnaire-2] was used, and that really focused on little interest or pleasure in doing things as number one, and then number two, feeling down, depressed, or hopeless.
So, as you can see, there are some distinctions, but some overlap as one would think. Also, the trend actually for the result that we showed for the two measurements mirrored one another.
Dr Green: This is really interesting how you set this up and used these validated measures. What were the findings in the study?
Dr Armstrong: What we found is that patients with moderate to severe psychological distress were about two to three times more likely to report low satisfaction with their doctors as compared with those patients who had no or little psychological distress.
When we looked at depression symptoms, patients with moderate to severe depression symptoms were about four times more likely to report low satisfactions with their doctors as compared with patients who had no or mild depression symptoms.
Dr Green: So, it appears that if someone has psychological distress before they see us, or even more noticeably depression, they’re much more likely to be unhappy with us no matter what we’re trying to do to help them.
Dr Armstrong: That’s absolutely right.
Dr Green: So, what would you say? How would you make sense of this? What would you say to us practicing dermatologists from looking at this data?
Dr Armstrong: As you said, Larry, what we found was that regardless of sociodemographic factors or comorbidities, and our analysis had adjusted for those, patients with psychological distress and depressive symptoms are more likely to report lower [physician] satisfaction.
There are several ways in which we can try to think about making sense of this data. One is that even if clinicians delivered, let’s say consistent, high-quality care, some patients may perceive such care to be inferior, owing at least in part to their baseline mental health status. So, for example, a patient who is depressed at baseline may be more likely than another patient without depression to rate the clinician poorly.
What we noted is that while this is new in the field of dermatology, when we look at other fields, this type of finding seems to be supported. For example, in cardiovascular medicine, what they found is that in patients with chronic coronary disease for example, depressive symptoms were strongly associated with a negative perception of their clinician.
I think another factor that may be adding another layer of interpretation to this is that in some patients, there could be possible cognitive impairments that are associated with depression and other types of mental health comorbidities. [These impairments] may affect their ability to engage with a clinician effectively or recall the information from the visit.
Dr Green: I think that’s really interesting, because no matter how many times we say something or think we have said to the patient what to do, how to take care of themselves, what we’re expecting, how they’ll get better, they may not be able to internalize that if they’re depressed or they have psychological distress. So, that’s something we have to take into effect, I guess, when we see the patient.
Dr Armstrong: Yes, absolutely.
Dr Green: So, let me ask you this. What about if we have patients doing well, and we want to put them on a biologic, and they’re using a biologic, yet they’re still depressed? So, is there any data that shows that they’re still going to be less happy with us?
Dr Armstrong: You know, that’s a great question. The average data [shows that] typically when patients are placed on an effective therapy, whether be it biologic or other types of therapy, that their overall mental health measures improve, so they get happier.
Now, if you have a patient to whom we have given what we think is an effective therapy for their skin, and their psoriasis is improving but perhaps their mental health aspects are not improving as much, I think it’s really important to address other factors that may be contributing to their existing mental health comorbidity.
For those patients, it may be important to really look at other factors that may be affecting them in terms of their social environment, in terms of other underlying mental health comorbidities that may need to be addressed by other health care professionals.
Editor’s note: This transcript has been edited for clarity.
1. Read C, Armstrong AW. Association between the mental health of patients with psoriasis and their satisfaction with physicians. JAMA Dermatol. 2020;156(7):754-762. doi:10.1001/jamadermatol.2020.1054